Healthcare Provider Details

I. General information

NPI: 1699735050
Provider Name (Legal Business Name): LEONARDO MANUEL RIOS-ANDERSEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12641 OLD GLENN HWY STE 103
EAGLE RIVER AK
99577-7040
US

IV. Provider business mailing address

12641 OLD GLENN HWY STE 103
EAGLE RIVER AK
99577-7040
US

V. Phone/Fax

Practice location:
  • Phone: 907-726-5600
  • Fax: 907-726-5602
Mailing address:
  • Phone: 907-726-5600
  • Fax: 907-726-5602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number02558
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEND1448
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: