Healthcare Provider Details

I. General information

NPI: 1346254851
Provider Name (Legal Business Name): ORAL SURGERY ASSOCIATES OF ALASKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W 16TH AVE SUITE 203
ANCHORAGE AK
99501-6206
US

IV. Provider business mailing address

111 W 16TH AVE SUITE 203
ANCHORAGE AK
99501-6206
US

V. Phone/Fax

Practice location:
  • Phone: 907-561-1430
  • Fax: 907-561-2697
Mailing address:
  • Phone: 907-561-1430
  • Fax: 907-561-2697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number18698
License Number StateAK

VIII. Authorized Official

Name: DR. WILLIAM RANDY DEETER
Title or Position: PRESIDENT
Credential: DDS
Phone: 907-561-1430