Provider Demographics
NPI:1376089128
Name:CAMAI DENTAL CLINIC LLC
Entity Type:Organization
Organization Name:CAMAI DENTAL CLINIC LLC
Other - Org Name:DENTAL INNOVATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-357-5214
Mailing Address - Street 1:3161 E PALMER WASILLA HWY
Mailing Address - Street 2:STE 5
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7271
Mailing Address - Country:US
Mailing Address - Phone:907-357-5214
Mailing Address - Fax:907-357-5213
Practice Address - Street 1:3161 E PALMER WASILLA HWY
Practice Address - Street 2:STE 5
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7271
Practice Address - Country:US
Practice Address - Phone:907-357-5214
Practice Address - Fax:907-357-5213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1003119Medicaid