Provider Demographics
NPI:1053994707
Name:DEMIDOVA, ALEXANDRA (DMD)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:DEMIDOVA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 E GLENSPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-8244
Mailing Address - Country:US
Mailing Address - Phone:910-884-8182
Mailing Address - Fax:
Practice Address - Street 1:235 SAINT JOHN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:FLETCHER
Practice Address - State:NC
Practice Address - Zip Code:28732
Practice Address - Country:US
Practice Address - Phone:828-654-7450
Practice Address - Fax:828-654-8665
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC12288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program