Provider Demographics
NPI:1932543345
Name:PETERSBURG DENTAL, INC.
Entity Type:Organization
Organization Name:PETERSBURG DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:LISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-772-9246
Mailing Address - Street 1:PO BOX 469
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-0469
Mailing Address - Country:US
Mailing Address - Phone:907-772-9246
Mailing Address - Fax:907-772-9278
Practice Address - Street 1:806 S. NORDIC DR.
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833-0469
Practice Address - Country:US
Practice Address - Phone:907-772-9246
Practice Address - Fax:907-772-9278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1096122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD54042Medicaid