Provider Demographics
NPI:1487197463
Name:NORTHERN DENTISTRY INC.
Entity Type:Organization
Organization Name:NORTHERN DENTISTRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:CORDOVA JR.
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-869-4435
Mailing Address - Street 1:951 E BOGARD RD
Mailing Address - Street 2:STE. #203
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7175
Mailing Address - Country:US
Mailing Address - Phone:907-376-2456
Mailing Address - Fax:907-376-2458
Practice Address - Street 1:951 E BOGARD RD
Practice Address - Street 2:STE. #203
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7175
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:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10026764122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty