Healthcare Provider Details

I. General information

NPI: 1629319132
Provider Name (Legal Business Name): KENNETH M EBERLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 ARCTIC BLVD STE 202
ANCHORAGE AK
99503-5769
US

IV. Provider business mailing address

3909 ARCTIC BLVD STE 202
ANCHORAGE AK
99503-5769
US

V. Phone/Fax

Practice location:
  • Phone: 907-344-8383
  • Fax: 907-344-8384
Mailing address:
  • Phone: 907-344-8383
  • Fax: 907-344-8384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberAAO554
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: