Provider Demographics
NPI:1609055029
Name:PETE B HIGGINS DDS LLC
Entity Type:Organization
Organization Name:PETE B HIGGINS DDS LLC
Other - Org Name:FOUR CORNERS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-479-7771
Mailing Address - Street 1:4001 GEIST RD STE 3
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3569
Mailing Address - Country:US
Mailing Address - Phone:907-479-7771
Mailing Address - Fax:907-479-7772
Practice Address - Street 1:4001 GEIST RD STE 3
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3569
Practice Address - Country:US
Practice Address - Phone:907-479-7771
Practice Address - Fax:907-479-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1012261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD10122Medicaid
1568540946OtherINDIVIDUAL NPI
AKDD10121Medicaid