Provider Demographics
NPI:1730793803
Name:MACK, ALEXIS MARIE (DDS)
Entity type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:MARIE
Last Name:MACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13606 XAVIER LANE SUITE B
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023
Mailing Address - Country:US
Mailing Address - Phone:303-466-7306
Mailing Address - Fax:303-466-7389
Practice Address - Street 1:13606 XAVIER LANE SUITE B
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023
Practice Address - Country:US
Practice Address - Phone:303-466-7306
Practice Address - Fax:303-466-7389
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002044541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice