Provider Demographics
NPI:1790898898
Name:JEDLICKA, GEORGE A (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:A
Last Name:JEDLICKA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 W BERING
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-0000
Mailing Address - Country:US
Mailing Address - Phone:907-262-2476
Mailing Address - Fax:
Practice Address - Street 1:44604 STERLING HWY #D
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-0000
Practice Address - Country:US
Practice Address - Phone:907-260-4700
Practice Address - Fax:907-260-4004
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD11061Medicaid