Provider Demographics
NPI:1346466075
Name:WASSELLE, GERARD W (DMD)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:W
Last Name:WASSELLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 ABBOTT RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-3867
Mailing Address - Country:US
Mailing Address - Phone:907-344-1990
Mailing Address - Fax:907-344-4426
Practice Address - Street 1:2020 ABBOTT RD
Practice Address - Street 2:SUITE 5
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-3867
Practice Address - Country:US
Practice Address - Phone:907-344-1990
Practice Address - Fax:907-344-4426
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK008361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD2020Medicaid