Healthcare Provider Details

I. General information

NPI: 1457609083
Provider Name (Legal Business Name): FAMILY MEDICAL DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4361 BONIFACE PKWY
ANCHORAGE AK
99504-4316
US

IV. Provider business mailing address

4361 BONIFACE PKWY
ANCHORAGE AK
99504-4316
US

V. Phone/Fax

Practice location:
  • Phone: 907-333-1211
  • Fax: 907-333-8600
Mailing address:
  • Phone: 907-333-1211
  • Fax: 907-333-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number978293
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number978293
License Number StateAK

VIII. Authorized Official

Name: JANICE KNIGHT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 907-333-1211