Provider Demographics
NPI:1134272768
Name:KOLEAN, BEN T (DDS)
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:T
Last Name:KOLEAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 E WESTPOINT DR
Mailing Address - Street 2:STE 112
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-376-4415
Mailing Address - Fax:907-373-0589
Practice Address - Street 1:851 E WESTPOINT DR STE 112
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7183
Practice Address - Country:US
Practice Address - Phone:907-376-4415
Practice Address - Fax:907-373-0589
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK043784444OtherTAX ID #
AKDD10871Medicaid