Provider Demographics
NPI:1770250292
Name:MINNIE STREET CHILDREN'S DENTISTRY, PC
Entity Type:Organization
Organization Name:MINNIE STREET CHILDREN'S DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-479-8844
Mailing Address - Street 1:114 MINNIE ST STE B
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3000
Mailing Address - Country:US
Mailing Address - Phone:907-308-2200
Mailing Address - Fax:
Practice Address - Street 1:114 MINNIE ST STE B
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3000
Practice Address - Country:US
Practice Address - Phone:907-308-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKUNKNOWNOtherUNKNOWN