Provider Demographics
NPI:1457027443
Name:OWLETUCK, GWENDOLYN AGNES
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:AGNES
Last Name:OWLETUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-679-2204
Mailing Address - Fax:907-543-6399
Practice Address - Street 1:700 CHIEF EDDIE HOFFMAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0528
Practice Address - Country:US
Practice Address - Phone:907-679-2204
Practice Address - Fax:907-543-6399
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK21-159-DHAT125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist