Healthcare Provider Details

I. General information

NPI: 1063231488
Provider Name (Legal Business Name): DUCLOS ORTHO ANCHORAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 W NORTHERN LIGHTS BLVD
ANCHORAGE AK
99517-3342
US

IV. Provider business mailing address

1836 W NORTHERN LIGHTS BLVD
ANCHORAGE AK
99517-3342
US

V. Phone/Fax

Practice location:
  • Phone: 907-272-3200
  • Fax: 907-272-3202
Mailing address:
  • Phone: 907-272-3200
  • Fax: 907-272-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JACK B DUCLOS
Title or Position: ORTHODONTIST
Credential: DDS
Phone: 907-272-3200