Healthcare Provider Details

I. General information

NPI: 1477227353
Provider Name (Legal Business Name): GINO MICHAEL AN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 NEELY RD
FORT WAINWRIGHT AK
99703
US

IV. Provider business mailing address

1433 BEECHNUT ST UNIT 1
FORT WAINWRIGHT AK
99703
US

V. Phone/Fax

Practice location:
  • Phone: 907-361-5172
  • Fax:
Mailing address:
  • Phone: 270-881-8513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10679
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: