1710619440 NPI number — DR. REBECCA MARIE VANLAEKEN DMD

Table of content: DR. REBECCA MARIE VANLAEKEN DMD (NPI 1710619440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710619440 NPI number — DR. REBECCA MARIE VANLAEKEN DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANLAEKEN
Provider First Name:
REBECCA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

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:
1710619440
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4076 NEELY ROAD, ROOM 3C-404
Provider Second Line Business Mailing Address:
ATTN: MCUC-MMD
Provider Business Mailing Address City Name:
FORT WAINWRIGHT
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4076 NEELY ROAD, ROOM 3C-404
Provider Second Line Business Practice Location Address:
ATTN: MCUC-MMD
Provider Business Practice Location Address City Name:
FORT WAINWRIGHT
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-361-6028
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  H4739 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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