Provider Demographics
NPI:1790858207
Name:PREMIUM ASPECT DENTISTRY, LLC
Entity Type:Organization
Organization Name:PREMIUM ASPECT DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-235-3618
Mailing Address - Street 1:345 STERLING HWY
Mailing Address - Street 2:SUITE 102A
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7820
Mailing Address - Country:US
Mailing Address - Phone:907-235-3618
Mailing Address - Fax:907-235-6849
Practice Address - Street 1:345 STERLING HWY
Practice Address - Street 2:SUITE 102A
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7820
Practice Address - Country:US
Practice Address - Phone:907-235-3618
Practice Address - Fax:907-235-6849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA06491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK663219OtherCLAIMS SUBMISSION ID
AKDD06492Medicaid