1013528090 NPI number — SPRUCE ROOTS FAMILY DENTISTRY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013528090 NPI number — SPRUCE ROOTS FAMILY DENTISTRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRUCE ROOTS FAMILY DENTISTRY, 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:
1013528090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4001 GEIST RD
Provider Second Line Business Mailing Address:
STE 5
Provider Business Mailing Address City Name:
FAIRBANKS
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99709-3569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-479-3326
Provider Business Mailing Address Fax Number:
907-479-6410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 GEIST RD
Provider Second Line Business Practice Location Address:
STE 5
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99709-3569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-479-3326
Provider Business Practice Location Address Fax Number:
907-479-6410
Provider Enumeration Date:
08/12/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
907-479-3326

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)





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