Provider Demographics
NPI:1164685806
Name:FRONTIER DENTAL, LLC
Entity Type:Organization
Organization Name:FRONTIER DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLDHAM
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-563-5820
Mailing Address - Street 1:3650 LAKE OTIS PKWY
Mailing Address - Street 2:STE 102
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5218
Mailing Address - Country:US
Mailing Address - Phone:907-563-5820
Mailing Address - Fax:
Practice Address - Street 1:3650 LAKE OTIS PKWY
Practice Address - Street 2:STE 102
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5218
Practice Address - Country:US
Practice Address - Phone:907-563-3820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA7071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD7070Medicaid