Healthcare Provider Details

I. General information

NPI: 1205265345
Provider Name (Legal Business Name): CORA ROBERTS DHAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 3RD AVENUE, SUITE 115
SEWARD AK
99664
US

IV. Provider business mailing address

PO BOX 103
HOONAH AK
99829-0103
US

V. Phone/Fax

Practice location:
  • Phone: 907-224-4925
  • Fax: 907-224-4933
Mailing address:
  • Phone: 907-945-3235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number13-114-DHAT
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: