Healthcare Provider Details

I. General information

NPI: 1093326308
Provider Name (Legal Business Name): MOLAR BEAR PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 S KNIK GOOSE BAY RD STE D
WASILLA AK
99654-8079
US

IV. Provider business mailing address

609 S KNIK GOOSE BAY RD STE D
WASILLA AK
99654-8079
US

V. Phone/Fax

Practice location:
  • Phone: 907-376-6527
  • Fax:
Mailing address:
  • Phone: 907-376-6527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. CHRISTOPHER G ROSENVALL
Title or Position: CEO
Credential: DDS
Phone: 801-592-7595