Provider Demographics
NPI:1780706838
Name:SOUTHEAST DENTAL GROUP, PC
Entity type:Organization
Organization Name:SOUTHEAST DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-586-9885
Mailing Address - Street 1:2220 DUNN ST
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-9304
Mailing Address - Country:US
Mailing Address - Phone:907-586-9885
Mailing Address - Fax:907-586-1849
Practice Address - Street 1:2220 DUNN ST
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1430
Practice Address - Country:US
Practice Address - Phone:907-586-9885
Practice Address - Fax:907-586-1849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7435122300000X
CO7113122300000X
AK9611223S0112X
AK963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDDO961Medicaid
AK963OtherSTATE OF ALASKA