Healthcare Provider Details

I. General information

NPI: 1306987532
Provider Name (Legal Business Name): COPPER RIVER NATIVE ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GLENN HWY. 187 MP
GLENNALLEN AK
99588-0744
US

IV. Provider business mailing address

187 GLENN HIGHWAY
GLENNALLEN AK
99588-0744
US

V. Phone/Fax

Practice location:
  • Phone: 907-822-3113
  • Fax: 907-822-4045
Mailing address:
  • Phone: 907-822-3113
  • Fax: 907-822-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number36087
License Number StateAK

VIII. Authorized Official

Name: ARLENE DILTS JACKSON
Title or Position: CEO
Credential:
Phone: 907-822-5241