Healthcare Provider Details

I. General information

NPI: 1356765838
Provider Name (Legal Business Name): ELSIE PELOWOOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GREG KRUSCHEK AVE
NOME AK
99762
US

IV. Provider business mailing address

PO BOX 112
SAVOONGA AK
99769
US

V. Phone/Fax

Practice location:
  • Phone: 907-443-3309
  • Fax: 907-443-3723
Mailing address:
  • Phone: 907-443-3309
  • Fax: 907-443-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number14-117-DHAT
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: