Provider Demographics
NPI:1831677814
Name:KELLY MAIXNER DMD LLC DBA WEE CARE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:KELLY MAIXNER DMD LLC DBA WEE CARE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-373-6000
Mailing Address - Street 1:1001 E USA CIR STE B
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7198
Mailing Address - Country:US
Mailing Address - Phone:907-373-6000
Mailing Address - Fax:907-357-6878
Practice Address - Street 1:1001 E USA CIR STE B
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7198
Practice Address - Country:US
Practice Address - Phone:907-373-6000
Practice Address - Fax:907-357-6878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1003575Medicaid