Healthcare Provider Details

I. General information

NPI: 1023294113
Provider Name (Legal Business Name): LAKEVIEW DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 E WESTPOINT DR STE 112
WASILLA AK
99654-7183
US

IV. Provider business mailing address

851 E WESTPOINT DR STE 112
WASILLA AK
99654-7183
US

V. Phone/Fax

Practice location:
  • Phone: 907-376-4415
  • Fax:
Mailing address:
  • Phone: 907-376-4415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number348
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number348
License Number StateAK

VIII. Authorized Official

Name: JEAN KINGSLIEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 907-376-4415