Provider Demographics
NPI:1568616548
Name:PEDIATRIC DENTISTRY OF ALASKA
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF ALASKA
Other - Org Name:PEDIATRIC DENTISTRY OF ALASKA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDA
Authorized Official - Phone:907-373-8684
Mailing Address - Street 1:3470 E MERIDIAN PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-373-8684
Mailing Address - Fax:907-373-8465
Practice Address - Street 1:3470 E MERIDIAN PARK LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-373-8684
Practice Address - Fax:907-373-8465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK9241223P0221X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1583802Medicaid
AK1003811Medicaid