Provider Demographics
NPI:1790320513
Name:OKITKUN, RUBY
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:OKITKUN
Suffix:
Gender:F
Credentials:
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 246
Mailing Address - Street 2:
Mailing Address - City:EMMONAK
Mailing Address - State:AK
Mailing Address - Zip Code:99581-0246
Mailing Address - Country:US
Mailing Address - Phone:907-949-3500
Mailing Address - Fax:
Practice Address - Street 1:700 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK13-116-DHAT125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist