Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 26653 | CA |
NPI | 1013018274 |
---|---|
Provider Name | Alexander Eugene Ivanoff |
First Address | Sonoma, CA 95476-3629 |
Second Address | Sonoma, CA 95476-3629 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2006 |
Last Update Date | 06/05/2009 |