Healthcare Provider Details

I. General information

NPI: 1437568409
Provider Name (Legal Business Name): NORTHERN LIGHTS DENTAL ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 08/21/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 W NORTHERN LIGHTS BLVD STE 623
ANCHORAGE AK
99503-2337
US

IV. Provider business mailing address

205 E DIMOND BLVD # 200
ANCHORAGE AK
99515-1909
US

V. Phone/Fax

Practice location:
  • Phone: 907-268-3109
  • Fax:
Mailing address:
  • Phone: 907-268-3109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number1547
License Number StateAK

VIII. Authorized Official

Name: DR. KENLEY DANE MICHAUD
Title or Position: CEO
Credential: DDS
Phone: 907-268-3109