Provider Demographics
NPI:1457609083
Name:FAMILY MEDICAL DENTAL CENTER LLC
Entity Type:Organization
Organization Name:FAMILY MEDICAL DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-333-1211
Mailing Address - Street 1:4361 BONIFACE PKWY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4316
Mailing Address - Country:US
Mailing Address - Phone:907-333-1211
Mailing Address - Fax:907-333-8600
Practice Address - Street 1:4361 BONIFACE PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4316
Practice Address - Country:US
Practice Address - Phone:907-333-1211
Practice Address - Fax:907-333-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK9782931223G0001X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty