Provider Demographics
NPI: | 1821285099 |
---|---|
Name: | ALASKA PREMIER DENTAL GROUP WASILLA, LLC |
Entity Type: | Organization |
Organization Name: | ALASKA PREMIER DENTAL GROUP WASILLA, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KENDALL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SKINNER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 907-337-0404 |
Mailing Address - Street 1: | 6611 DEBARR RD |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | ANCHORAGE |
Mailing Address - State: | AK |
Mailing Address - Zip Code: | 99504-1706 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 935 E WESTPOINT DR |
Practice Address - Street 2: | SUITE 202 |
Practice Address - City: | WASILLA |
Practice Address - State: | AK |
Practice Address - Zip Code: | 99654-7143 |
Practice Address - Country: | US |
Practice Address - Phone: | 907-373-5930 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-10-01 |
Last Update Date: | 2007-10-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AK | 111306 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |