1831677814 NPI number — KELLY MAIXNER DMD LLC DBA WEE CARE PEDIATRIC DENTISTRY

Table of content: KATIE YEAGER PLOURD CRNP (NPI 1013259506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831677814 NPI number — KELLY MAIXNER DMD LLC DBA WEE CARE PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLY MAIXNER DMD LLC DBA WEE CARE PEDIATRIC DENTISTRY
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:
1831677814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 E USA CIR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASILLA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99654-7198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-373-6000
Provider Business Mailing Address Fax Number:
907-357-6878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 E USA CIR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654-7198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-373-6000
Provider Business Practice Location Address Fax Number:
907-357-6878
Provider Enumeration Date:
08/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
FORREST
Authorized Official First Name:
MISTI
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
907-373-6000

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  1248 , 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: 1003575 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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