Provider Demographics
NPI:1518574052
Name:EVERGREEN DENTAL, LLC
Entity Type:Organization
Organization Name:EVERGREEN DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:FETUAO
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-276-4537
Mailing Address - Street 1:125 W EVERGREEN AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6908
Mailing Address - Country:US
Mailing Address - Phone:907-531-3477
Mailing Address - Fax:
Practice Address - Street 1:125 W EVERGREEN AVE STE 204
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6908
Practice Address - Country:US
Practice Address - Phone:907-531-3477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1922430040Medicaid
AK1417158080Medicaid