Provider Demographics
NPI:1831550631
Name:FAIRBANKS DENTAL CENTER LLC
Entity type:Organization
Organization Name:FAIRBANKS DENTAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:STOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-452-1250
Mailing Address - Street 1:3112 AIRPORT WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4768
Mailing Address - Country:US
Mailing Address - Phone:907-452-1250
Mailing Address - Fax:907-456-1307
Practice Address - Street 1:3112 AIRPORT WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4768
Practice Address - Country:US
Practice Address - Phone:907-452-1250
Practice Address - Fax:907-456-1307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X2210XDental ProvidersDentistOrofacial PainGroup - Multi-Specialty