Healthcare Provider Details

I. General information

NPI: 1518187210
Provider Name (Legal Business Name): JACK B DUCLOS D.D.S, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
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:
Mailing address:
  • Phone: 907-272-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number871
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: