Healthcare Provider Details

I. General information

NPI: 1902653264
Provider Name (Legal Business Name): WILLIAM COLTON GODFREY DHAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 DIPLOMACY DR
ANCHORAGE AK
99508-5910
US

IV. Provider business mailing address

7033 E TUDOR RD
ANCHORAGE AK
99507-1262
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-2000
  • Fax:
Mailing address:
  • Phone: 907-729-8961
  • Fax: 907-729-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number24-181-DHAT
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: