Provider Demographics
NPI:1578010476
Name:SOUTHCENTRAL FOUNDATION
Entity Type:Organization
Organization Name:SOUTHCENTRAL FOUNDATION
Other - Org Name:NEWHALEN DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-317-6070
Mailing Address - Street 1:PO BOX 35151
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-5151
Mailing Address - Country:US
Mailing Address - Phone:907-317-6070
Mailing Address - Fax:907-729-5178
Practice Address - Street 1:102 FIREWEED LANE
Practice Address - Street 2:
Practice Address - City:NEWHALEN
Practice Address - State:AK
Practice Address - Zip Code:99606
Practice Address - Country:US
Practice Address - Phone:907-571-1231
Practice Address - Fax:907-571-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK204671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty