Provider Demographics
NPI:1417177346
Name:MAT-SU DENTAL CENTER, INC.
Entity Type:Organization
Organization Name:MAT-SU DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-376-2456
Mailing Address - Street 1:951 BOGARD RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7113
Mailing Address - Country:US
Mailing Address - Phone:907-376-2456
Mailing Address - Fax:907-376-2458
Practice Address - Street 1:951 BOGARD RD
Practice Address - Street 2:SUITE 203
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7113
Practice Address - Country:US
Practice Address - Phone:907-376-2456
Practice Address - Fax:907-376-2458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2852491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty