Provider Demographics
NPI:1013528090
Name:SPRUCE ROOTS FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:SPRUCE ROOTS FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-479-3326
Mailing Address - Street 1:4001 GEIST RD
Mailing Address - Street 2:STE 5
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3569
Mailing Address - Country:US
Mailing Address - Phone:907-479-3326
Mailing Address - Fax:907-479-6410
Practice Address - Street 1:4001 GEIST RD
Practice Address - Street 2:STE 5
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3569
Practice Address - Country:US
Practice Address - Phone:907-479-3326
Practice Address - Fax:907-479-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty