Provider Demographics
NPI:1669065132
Name:49TH STATE FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:49TH STATE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOHUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-561-5154
Mailing Address - Street 1:10998 OMALLEY CENTRE DR STE A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-3168
Mailing Address - Country:US
Mailing Address - Phone:907-561-5154
Mailing Address - Fax:907-561-2253
Practice Address - Street 1:10998 OMALLEY CENTRE DR STE A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3168
Practice Address - Country:US
Practice Address - Phone:907-561-5154
Practice Address - Fax:907-561-2253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1114268711OtherTYPE 1 NPI