Provider Demographics
NPI:1376982918
Name:FAIRBANKS ORTHODONTIC GROUP, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:FAIRBANKS ORTHODONTIC GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-452-2939
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-452-2939
Mailing Address - Fax:907-451-7330
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-452-2939
Practice Address - Fax:907-451-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1249261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKGR0227Medicaid