Healthcare Provider Details

I. General information

NPI: 1568616548
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF ALASKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3470 E MERIDIAN PARK LOOP
WASILLA AK
99654
US

IV. Provider business mailing address

3470 E MERIDIAN PARK LOOP
WASILLA AK
99654
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-8684
  • Fax: 907-373-8465
Mailing address:
  • Phone: 907-373-8684
  • Fax: 907-373-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number924
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number924
License Number StateAK

VII. Legacy identifiers

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

# 1
Identifier1583802
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
Identifier1003811
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: ROGER DUANE BECK
Title or Position: OWNER/PRESIDENT
Credential: DDA
Phone: 907-373-8684