Provider Demographics
NPI:1255362901
Name:KWASINSKI, MICHAEL RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:KWASINSKI
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 1:798 CRANBERRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99712-1103
Mailing Address - Country:US
Mailing Address - Phone:907-474-0715
Mailing Address - Fax:
Practice Address - Street 1:122 1ST AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4803
Practice Address - Country:US
Practice Address - Phone:907-452-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK9331223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health