MEDICARE: KETCHIKAN DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1518720911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETCHIKAN DENTAL

Provider Business Mailing Address
First Line	:	130 CARLANNA LAKE RD
Second Line	:
City	:	KETCHIKAN
State	:	AK
Zip	:	99901-5669
Country	:	US
Telephone Number	:	909-967-8052
Fax Number	:	907-331-4220

Provider Business Practice Location Address
First Line	:	130 CARLANNA LAKE RD
Second Line	:
City	:	KETCHIKAN
State	:	AK
Zip	:	99901-5669
Country	:	US
Telephone Number	:	909-967-8052
Fax Number	:	907-331-4220

Authorized Official
Title or Position	:	OWNER
Name	:	TANNER D ZYLSTRA
Credential	:	DDS
Telephone Number	:	909-967-8052

Provider Enumeration Date	:	01/30/2024
Last Update Date	:	01/30/2024

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Directions to “KETCHIKAN DENTAL ” Practice Location

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