Healthcare Provider Details

I. General information

NPI: 1134512676
Provider Name (Legal Business Name): ANGELICA AFCAN DHAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 CHIEF EDDIE HOFFMAN HIGHWAY
BETHEL AK
99559
US

IV. Provider business mailing address

PO BOX 528
BETHEL AK
99559-0528
US

V. Phone/Fax

Practice location:
  • Phone: 907-543-6200
  • Fax: 907-543-6393
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number15-122-DHAT
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: