Healthcare Provider Details

I. General information

NPI: 1609283670
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 DIPLOMACY DR
ANCHORAGE AK
99508-5926
US

IV. Provider business mailing address

PO BOX 35151
SEATTLE WA
98124-5198
US

V. Phone/Fax

Practice location:
  • Phone: 907-317-6070
  • Fax: 907-729-5178
Mailing address:
  • Phone: 907-317-6070
  • Fax: 907-729-5178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KATHRYN S MILLER
Title or Position: PATIENT ACCOUNTS MANAGER
Credential: CPC, CDC
Phone: 907-317-6070