Provider Demographics
NPI:1346254851
Name:ORAL SURGERY ASSOCIATES OF ALASKA
Entity Type:Organization
Organization Name:ORAL SURGERY ASSOCIATES OF ALASKA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RANDY
Authorized Official - Last Name:DEETER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-561-1430
Mailing Address - Street 1:111 W 16TH AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-6206
Mailing Address - Country:US
Mailing Address - Phone:907-561-1430
Mailing Address - Fax:907-561-2697
Practice Address - Street 1:111 W 16TH AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-6206
Practice Address - Country:US
Practice Address - Phone:907-561-1430
Practice Address - Fax:907-561-2697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK186981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDDG001Medicaid
AK1518402OtherUNITED CON ID
AKGRO153Medicaid