1629214705 NPI number — EAGLE SUMMIT DENTAL GROUP

Table of content: (NPI 1629214705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629214705 NPI number — EAGLE SUMMIT DENTAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE SUMMIT DENTAL GROUP
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:
MICHAEL SANDERS DMD PC
Provider Other Organization Name Type Code:
4
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:
1629214705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13015 OLD GLENN HWY
Provider Second Line Business Mailing Address:
#200
Provider Business Mailing Address City Name:
EAGLE RIVER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99577-8080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-694-8234
Provider Business Mailing Address Fax Number:
907-697-8225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13015 OLD GLENN HWY
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
EAGLE RIVER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-694-8234
Provider Business Practice Location Address Fax Number:
907-697-8225
Provider Enumeration Date:
12/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SANDERS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
ROLAND
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
907-694-8234

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  1086 , 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: 1086 . This is a "STATE LICENSE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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