1568623106 NPI number — SOUTH ANCHORAGE DENTAL CLINIC LLC

Table of content: MRS. CLAUDIA BETH FAGILDE NP (NPI 1780795021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568623106 NPI number — SOUTH ANCHORAGE DENTAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH ANCHORAGE DENTAL CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1568623106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9170 JEWEL LAKE ROAD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-248-7275
Provider Business Mailing Address Fax Number:
907-248-7221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9170 JEWEL LAKE ROAD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-248-7275
Provider Business Practice Location Address Fax Number:
907-248-7221
Provider Enumeration Date:
06/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HEBERTSON
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
907-248-7275

Provider Taxonomy Codes

  • Taxonomy code: 126800000X , with the licence number:  AA625 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 126800000X , with the licence number: 1009 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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