Healthcare Provider Details

I. General information

NPI: 1760356208
Provider Name (Legal Business Name): ADVANCED DERMATOLOGY OF ALASKA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3066 E MERIDIAN PARK LOOP
WASILLA AK
99654-7254
US

IV. Provider business mailing address

1100 E DIMOND BLVD STE 103
ANCHORAGE AK
99515-2001
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-2332
  • Fax:
Mailing address:
  • Phone: 907-232-0251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: BLAKE GALLER
Title or Position: OWNER
Credential: DO
Phone: 817-903-5886