Basic Information
Provider Information
NPI: 1003291154
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WENZEL
FirstName: ALEXANDRA
MiddleName: A
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 126
Address2:  
City: PRAIRIE DU SAC
State: WI
PostalCode: 535780126
CountryCode: US
TelephoneNumber: 6086433855
FaxNumber: 6086436295
Practice Location
Address1: 8667 US HIGHWAY 42 STE 100
Address2:  
City: UNION
State: KY
PostalCode: 410918759
CountryCode: US
TelephoneNumber: 8593840393
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/29/2015
LastUpdateDate: 11/07/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X10204KYY Dental ProvidersDentistGeneral Practice
1223G0001X30.025592OHN Dental ProvidersDentistGeneral Practice
1223G0001X100102CAN Dental ProvidersDentistGeneral Practice
1223G0001X1001182WIN Dental ProvidersDentistGeneral Practice

No ID Information.


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