Provider Demographics
NPI:1568776961
Name:DR. JAY R. DERKSEN D.D.S., INC
Entity Type:Organization
Organization Name:DR. JAY R. DERKSEN D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DERKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-276-5418
Mailing Address - Street 1:880 N ST
Mailing Address - Street 2:SUITE 223
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3276
Mailing Address - Country:US
Mailing Address - Phone:907-276-5418
Mailing Address - Fax:907-274-6427
Practice Address - Street 1:880 N ST
Practice Address - Street 2:SUITE 223
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3276
Practice Address - Country:US
Practice Address - Phone:907-276-5418
Practice Address - Fax:907-274-6427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA04741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty