Provider Demographics
NPI:1649385006
Name:DIMOND CHILDRENS DENTISTRY INC
Entity Type:Organization
Organization Name:DIMOND CHILDRENS DENTISTRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-336-7337
Mailing Address - Street 1:1310 EAST DIMOND BLVD #3
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515
Mailing Address - Country:US
Mailing Address - Phone:907-336-7337
Mailing Address - Fax:907-336-7338
Practice Address - Street 1:1310 EAST DIMOND BLVD #3
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515
Practice Address - Country:US
Practice Address - Phone:907-336-7337
Practice Address - Fax:907-336-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4321591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty