Provider Demographics
NPI:1407625510
Name:71 17 NORTH FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:71 17 NORTH FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-687-3491
Mailing Address - Street 1:4001 GEIST RD STE 5
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3569
Mailing Address - Country:US
Mailing Address - Phone:907-888-0057
Mailing Address - Fax:
Practice Address - Street 1:1616 OKPIK ST
Practice Address - Street 2:
Practice Address - City:UQTIAGVIK
Practice Address - State:AK
Practice Address - Zip Code:99723
Practice Address - Country:US
Practice Address - Phone:907-888-0057
Practice Address - Fax:907-479-6410
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPRUCE ROOTS FAMILY DENTISTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty