1316186281 NPI number — NINILCHIK FAMILY DENTISTRY P.C.

Table of content: DR. LISA JANE GILLIS MD (NPI 1639680614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316186281 NPI number — NINILCHIK FAMILY DENTISTRY P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NINILCHIK FAMILY DENTISTRY P.C.
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:
1316186281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 39450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NINILCHIK
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-567-4444
Provider Business Mailing Address Fax Number:
907-567-4446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66334 ASPEN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NINILCHIK
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-567-4444
Provider Business Practice Location Address Fax Number:
907-567-4446
Provider Enumeration Date:
02/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ZOUBEK
Authorized Official First Name:
ZESTIVINAL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
907-567-4444

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  1095 , 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: DD7097 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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