Provider Demographics
NPI:1831347889
Name:LAND, ALFRED MONTAGUE IV (DMD)
Entity type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:MONTAGUE
Last Name:LAND
Suffix:IV
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 1:951 E BOGARD RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7175
Mailing Address - Country:US
Mailing Address - Phone:907-376-2456
Mailing Address - Fax:
Practice Address - Street 1:10928 EAGLE RIVER RD
Practice Address - Street 2:SUITE 250
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8038
Practice Address - Country:US
Practice Address - Phone:907-696-4987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12751223G0001X
ORD91511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice