Healthcare Provider Details

I. General information

NPI: 1144155805
Provider Name (Legal Business Name): SOVEREIGN DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15701 E SPRAGUE AVE STE F
SPOKANE VALLEY WA
99037-5019
US

IV. Provider business mailing address

5401 E WINDRIDGE AVE
WASILLA AK
99654-6784
US

V. Phone/Fax

Practice location:
  • Phone: 480-341-0791
  • Fax:
Mailing address:
  • Phone: 480-341-0791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DERICK J SOVEREIGN
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 480-341-0791