Provider Demographics
NPI:1487671228
Name:NORDSTROM, HANS PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:HANS
Middle Name:PATRICK
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E USA CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7198
Mailing Address - Country:US
Mailing Address - Phone:907-357-6800
Mailing Address - Fax:907-357-6878
Practice Address - Street 1:1001 E USA CIR
Practice Address - Street 2:SUITE B
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7198
Practice Address - Country:US
Practice Address - Phone:907-357-6800
Practice Address - Fax:907-357-6878
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1135122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK01634756OtherTRICARE
AK0053521Medicaid