Healthcare Provider Details

I. General information

NPI: 1164441119
Provider Name (Legal Business Name): VALLEY ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 USA CIR
WASILLA AK
99654-7198
US

IV. Provider business mailing address

1001 USA CIR
WASILLA AK
99654-7198
US

V. Phone/Fax

Practice location:
  • Phone: 907-376-1510
  • Fax:
Mailing address:
  • Phone: 907-376-1510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number420264
License Number StateAK

VII. Legacy identifiers

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

# 1
Identifier01334405
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerUNITED CONCORDIA PROVIDER

VIII. Authorized Official

Name: DR. BRIAN DAVID HARTMAN
Title or Position: OWNER/ORTHODONTIST
Credential: D.M.D.
Phone: 907-376-1510