Provider Demographics
NPI:1760741177
Name:GEORGE JEDLICKA DMD, PC
Entity Type:Organization
Organization Name:GEORGE JEDLICKA DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEDLICKA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-260-4700
Mailing Address - Street 1:44604 STERLING HWY#D
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669
Mailing Address - Country:US
Mailing Address - Phone:907-260-4700
Mailing Address - Fax:907-260-4004
Practice Address - Street 1:44604 STERLING HWY#D
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-260-4700
Practice Address - Fax:907-260-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK#11061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD11061Medicaid