1093042194 NPI number — GLACIER DENTAL, LLC

Table of content: (NPI 1093042194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093042194 NPI number — GLACIER DENTAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLACIER DENTAL, 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:
6
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:
1093042194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8840 OLD SEWARD HIGHWAY, #F
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:
99515-2000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-222-6000
Provider Business Mailing Address Fax Number:
907-333-3390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2421 E TUDOR RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99507-1166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-222-6000
Provider Business Practice Location Address Fax Number:
907-333-3390
Provider Enumeration Date:
11/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JEON
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
907-222-6000

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  1239 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DD2134 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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