Provider Demographics
NPI:1831206226
Name:SPRAGUE, RICHARD E (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:SPRAGUE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 567
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833
Mailing Address - Country:US
Mailing Address - Phone:907-772-3320
Mailing Address - Fax:907-772-3320
Practice Address - Street 1:15 W EXCEL
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833
Practice Address - Country:US
Practice Address - Phone:907-772-3320
Practice Address - Fax:907-772-3320
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA3671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDDO 367Medicaid
AKAA367OtherSTATE LICENSE NUMBER