Provider Demographics
NPI:1437419447
Name:VALLEY DENTAL CLINIC
Entity Type:Organization
Organization Name:VALLEY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-376-3884
Mailing Address - Street 1:935 E WESTPOINT DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7181
Mailing Address - Country:US
Mailing Address - Phone:907-376-3884
Mailing Address - Fax:907-373-7500
Practice Address - Street 1:935 E WESTPOINT DR STE 201
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7181
Practice Address - Country:US
Practice Address - Phone:907-376-3884
Practice Address - Fax:907-373-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK991122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD2628Medicaid