Provider Demographics
NPI:1528181971
Name:ARCTIC SLOPE NATIVE ASSOCIATION
Entity Type:Organization
Organization Name:ARCTIC SLOPE NATIVE ASSOCIATION
Other - Org Name:SAMUEL SIMMONDS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR OF DENTAL
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHLEY-GAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-852-4611
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:1296 AGVIK ST
Mailing Address - City:BARROW
Mailing Address - State:AK
Mailing Address - Zip Code:99723-0029
Mailing Address - Country:US
Mailing Address - Phone:907-852-4611
Mailing Address - Fax:907-852-9297
Practice Address - Street 1:1296 AGVIK ST
Practice Address - Street 2:
Practice Address - City:BARROW
Practice Address - State:AK
Practice Address - Zip Code:99723
Practice Address - Country:US
Practice Address - Phone:907-852-4611
Practice Address - Fax:907-852-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKDD1010261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD1010Medicaid