Provider Demographics
NPI:1366670093
Name:TUDOR DENTAL GROUP LLC
Entity Type:Organization
Organization Name:TUDOR DENTAL GROUP LLC
Other - Org Name:MURPHY FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MJOLSNES
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:907-561-4047
Mailing Address - Street 1:330 E TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-7369
Mailing Address - Country:US
Mailing Address - Phone:907-561-4047
Mailing Address - Fax:907-562-9856
Practice Address - Street 1:330 E TUDOR RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-7369
Practice Address - Country:US
Practice Address - Phone:907-561-4047
Practice Address - Fax:907-562-9856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4421223G0001X
AK12341223G0001X
AK11311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK000823462OtherUNITED CONCORDIA
AKDD1686Medicaid
AKDD1741Medicaid
AKDDO442Medicaid
AK01630417OtherUNITED CONCORDIA