Healthcare Provider Details

I. General information

NPI: 1659687945
Provider Name (Legal Business Name): FAIRBANKS FOOT & ANKLE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 KELLUM ST. STE 200
FAIRBANKS AK
99701
US

IV. Provider business mailing address

1405 KELLUM ST. STE 200
FAIRBANKS AK
99701
US

V. Phone/Fax

Practice location:
  • Phone: 907-451-9202
  • Fax: 907-452-6256
Mailing address:
  • Phone: 907-451-9202
  • Fax: 907-452-6256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2810
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2810
License Number StateAK

VIII. Authorized Official

Name: DR. RALPH SYLVAN DIXON
Title or Position: OWNER/PRESIDENT
Credential: DPM
Phone: 907-451-9202