Provider Demographics
NPI:1811507262
Name:BERARDUCCI, ALEXANDER THOMAS (DMD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:THOMAS
Last Name:BERARDUCCI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 MCGREGOR LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-2276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-2841
Practice Address - Country:US
Practice Address - Phone:814-266-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist