Provider Demographics
NPI:1114432473
Name:SAME DAY DENTAL PALMER L.L.C.
Entity Type:Organization
Organization Name:SAME DAY DENTAL PALMER L.L.C.
Other - Org Name:SAME DAY DENTAL PALMER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-631-3630
Mailing Address - Street 1:125 W EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6908
Mailing Address - Country:US
Mailing Address - Phone:616-902-4077
Mailing Address - Fax:888-341-5659
Practice Address - Street 1:125 W EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6908
Practice Address - Country:US
Practice Address - Phone:616-902-4077
Practice Address - Fax:888-341-5659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK628261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1597353Medicaid