Healthcare Provider Details

I. General information

NPI: 1336783075
Provider Name (Legal Business Name): ALLISON KRISTI WASULI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 2ND AVENUE
KOTZEBUE AK
99752
US

IV. Provider business mailing address

PO BOX 805
KOTZEBUE AK
99752-0805
US

V. Phone/Fax

Practice location:
  • Phone: 907-412-2559
  • Fax:
Mailing address:
  • Phone: 907-412-2559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number19-153-DHAT
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: