Healthcare Provider Details

I. General information

NPI: 1790898898
Provider Name (Legal Business Name): GEORGE A JEDLICKA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44604 STERLING HWY #D
SOLDOTNA AK
99669-0000
US

IV. Provider business mailing address

312 W BERING
SOLDOTNA AK
99669-0000
US

V. Phone/Fax

Practice location:
  • Phone: 907-260-4700
  • Fax: 907-260-4004
Mailing address:
  • Phone: 907-262-2476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1106
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: