Provider Demographics
NPI:1568623106
Name:SOUTH ANCHORAGE DENTAL CLINIC LLC
Entity Type:Organization
Organization Name:SOUTH ANCHORAGE DENTAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:HEBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-248-7275
Mailing Address - Street 1:9170 JEWEL LAKE ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502
Mailing Address - Country:US
Mailing Address - Phone:907-248-7275
Mailing Address - Fax:907-248-7221
Practice Address - Street 1:9170 JEWEL LAKE ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502
Practice Address - Country:US
Practice Address - Phone:907-248-7275
Practice Address - Fax:907-248-7221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA625126800000X
AK1009126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126800000XDental ProvidersDental AssistantGroup - Multi-Specialty