Provider Demographics
NPI:1154672558
Name:MABRY AND MABRY DENTISTRY, LLC
Entity Type:Organization
Organization Name:MABRY AND MABRY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MABRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-337-9448
Mailing Address - Street 1:2601 BONIFACE PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3144
Mailing Address - Country:US
Mailing Address - Phone:907-337-9448
Mailing Address - Fax:907-337-4123
Practice Address - Street 1:2601 BONIFACE PKWY STE 1
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3144
Practice Address - Country:US
Practice Address - Phone:907-337-9448
Practice Address - Fax:907-337-4123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1200261QD0000X
AK377261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD2601Medicaid