Healthcare Provider Details

I. General information

NPI: 1760741177
Provider Name (Legal Business Name): GEORGE JEDLICKA DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44604 STERLING HWY#D
SOLDOTNA AK
99669
US

IV. Provider business mailing address

44604 STERLING HWY#D
SOLDOTNA AK
99669
US

V. Phone/Fax

Practice location:
  • Phone: 907-260-4700
  • Fax: 907-260-4004
Mailing address:
  • Phone: 907-260-4700
  • Fax: 907-260-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberAK#1106
License Number StateAK

VIII. Authorized Official

Name: DR. GEORGE A JEDLICKA
Title or Position: DENTIST
Credential: DMD
Phone: 907-260-4700