Provider Demographics
NPI:1629214705
Name:EAGLE SUMMIT DENTAL GROUP
Entity Type:Organization
Organization Name:EAGLE SUMMIT DENTAL GROUP
Other - Org Name:MICHAEL SANDERS DMD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROLAND
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-694-8234
Mailing Address - Street 1:13015 OLD GLENN HWY
Mailing Address - Street 2:#200
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8080
Mailing Address - Country:US
Mailing Address - Phone:907-694-8234
Mailing Address - Fax:907-697-8225
Practice Address - Street 1:13015 OLD GLENN HWY
Practice Address - Street 2:#200
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577
Practice Address - Country:US
Practice Address - Phone:907-694-8234
Practice Address - Fax:907-697-8225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1086122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1086OtherSTATE LICENSE