Healthcare Provider Details

I. General information

NPI: 1316492960
Provider Name (Legal Business Name): NORTH STAR ORAL & FACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 COWLES ST
FAIRBANKS AK
99701-5916
US

IV. Provider business mailing address

119 N CUSHMAN ST STE 400
FAIRBANKS AK
99701-2879
US

V. Phone/Fax

Practice location:
  • Phone: 907-374-8111
  • Fax: 907-374-8119
Mailing address:
  • Phone: 907-374-8111
  • Fax: 907-374-8119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number105542
License Number StateAK

VIII. Authorized Official

Name: DR. RICHARD WILLIAM HOMPESCH III
Title or Position: SOLE OWNER
Credential: DDS
Phone: 907-374-8111