Provider Demographics
NPI:1710310073
Name:FOUR CORNERS DENTAL GROUP FAIRBANKS
Entity Type:Organization
Organization Name:FOUR CORNERS DENTAL GROUP FAIRBANKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RHOTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-479-7771
Mailing Address - Street 1:3487 AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4761
Mailing Address - Country:US
Mailing Address - Phone:907-479-7771
Mailing Address - Fax:907-479-7772
Practice Address - Street 1:3487 AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4761
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:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0143Medicaid