Provider Demographics
NPI:1649384066
Name:GOTTLIEB, KEVIN (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 196320
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99519
Mailing Address - Country:US
Mailing Address - Phone:907-317-6070
Mailing Address - Fax:806-794-1919
Practice Address - Street 1:4201 TUDOR CENTRE DR
Practice Address - Street 2:SUITE 320
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5904
Practice Address - Country:US
Practice Address - Phone:907-317-6070
Practice Address - Fax:806-794-1919
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0465Medicaid
826285OtherUNITED CONCORDIA