1235151374 NPI number — JOE KOLIADKO DDS

Table of content: JOE KOLIADKO DDS (NPI 1235151374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235151374 NPI number — JOE KOLIADKO DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOLIADKO
Provider First Name:
JOE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235151374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 196320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99519-5904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-317-6070
Provider Business Mailing Address Fax Number:
806-794-1919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 TUDOR CENTRE DR
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-5904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-317-6070
Provider Business Practice Location Address Fax Number:
806-794-1919
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  AK1042 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DD2889 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1471866 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".




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