Healthcare Provider Details

I. General information

NPI: 1275075244
Provider Name (Legal Business Name): SUMMER MICHELE LYNCH DHAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 DALTON STREET SUITE 102
HAINES AK
99827
US

IV. Provider business mailing address

PO BOX 1529
HAINES AK
99827-1529
US

V. Phone/Fax

Practice location:
  • Phone: 907-766-6372
  • Fax:
Mailing address:
  • Phone: 907-766-6372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number16-139-DHA
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: