Provider Demographics
NPI:1093123879
Name:PENINSULA DENTAL CENTER
Entity Type:Organization
Organization Name:PENINSULA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-452-8296
Mailing Address - Street 1:47707 JUDY LYNN LN
Mailing Address - Street 2:
Mailing Address - City:SOLDONTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669
Mailing Address - Country:US
Mailing Address - Phone:907-283-9125
Mailing Address - Fax:907-283-9184
Practice Address - Street 1:47707 JUDY LYNN LANE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-283-9125
Practice Address - Fax:907-283-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK15721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty