1710099502 NPI number — ANCHORAGE DENTAL ARTS, LLC

Table of content: (NPI 1710099502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710099502 NPI number — ANCHORAGE DENTAL ARTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANCHORAGE DENTAL ARTS, 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:
1710099502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 CORDOVA ST STE 200
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:
99503-2745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-276-1712
Provider Business Mailing Address Fax Number:
907-258-4482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 CORDOVA ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99503-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-276-1712
Provider Business Practice Location Address Fax Number:
907-258-4482
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SWENSON
Authorized Official First Name:
MAX
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
907-276-1712

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01611666 . This is a "UNITED CONCORDIA ID #" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".