Provider Demographics
NPI:1205148301
Name:DENALI PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:DENALI PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:C
Authorized Official - Last Name:HENRIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-830-9771
Mailing Address - Street 1:2600 DENALI ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2746
Mailing Address - Country:US
Mailing Address - Phone:907-334-9543
Mailing Address - Fax:907-334-9007
Practice Address - Street 1:2600 DENALI ST
Practice Address - Street 2:SUITE 500
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2746
Practice Address - Country:US
Practice Address - Phone:907-334-9543
Practice Address - Fax:907-334-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental