Healthcare Provider Details

I. General information

NPI: 1225618481
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 DIPLOMACY DR
ANCHORAGE AK
99508-5910
US

IV. Provider business mailing address

PO BOX 35151
SEATTLE WA
98124-5151
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: RONALD LEE OLSON
Title or Position: EXECUTIVE VICE PRESIDENT FINANCE
Credential:
Phone: 907-729-4939