Healthcare Provider Details

I. General information

NPI: 1023267796
Provider Name (Legal Business Name): KEITH C COOMBS DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 RHONE CIR
ANCHORAGE AK
99508-5051
US

IV. Provider business mailing address

3708 RHONE CIR
ANCHORAGE AK
99508-5051
US

V. Phone/Fax

Practice location:
  • Phone: 907-563-3015
  • Fax: 907-562-7996
Mailing address:
  • Phone: 907-563-3015
  • Fax: 907-562-7996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number155
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: