Provider Demographics
NPI:1518720911
Name:KETCHIKAN DENTAL
Entity Type:Organization
Organization Name:KETCHIKAN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:D
Authorized Official - Last Name:ZYLSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-967-8052
Mailing Address - Street 1:130 CARLANNA LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5669
Mailing Address - Country:US
Mailing Address - Phone:909-967-8052
Mailing Address - Fax:907-331-4220
Practice Address - Street 1:130 CARLANNA LAKE RD
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5669
Practice Address - Country:US
Practice Address - Phone:909-967-8052
Practice Address - Fax:907-331-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty