Provider Demographics
NPI:1841580966
Name:SOUTH ANCHORAGE DENTAL CENTER
Entity Type:Organization
Organization Name:SOUTH ANCHORAGE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BROC
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BRIMHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-248-7275
Mailing Address - Street 1:9170 JEWEL LAKE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-5390
Mailing Address - Country:US
Mailing Address - Phone:907-248-7275
Mailing Address - Fax:907-248-7221
Practice Address - Street 1:9170 JEWEL LAKE RD STE 201
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-5390
Practice Address - Country:US
Practice Address - Phone:907-248-7275
Practice Address - Fax:907-248-7221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1308305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0040Medicaid