Provider Demographics
NPI:1811568900
Name:KODIAK ISLAND FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KODIAK ISLAND FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-481-3567
Mailing Address - Street 1:204 E REZANOF DR STE 201
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6379
Mailing Address - Country:US
Mailing Address - Phone:907-481-3567
Mailing Address - Fax:
Practice Address - Street 1:204 E REZANOF DR STE 201
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6379
Practice Address - Country:US
Practice Address - Phone:907-481-3567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1437243326Medicaid
AK1326421850Medicaid
AK1639787021Medicaid