Healthcare Provider Details

I. General information

NPI: 1376099044
Provider Name (Legal Business Name): ALPINE FAMILY DENTAL CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 DEER LANE
ALPINE WY
83128
US

IV. Provider business mailing address

5018 E 41 N
RIRIE ID
83443-5038
US

V. Phone/Fax

Practice location:
  • Phone: 907-441-4569
  • Fax:
Mailing address:
  • Phone: 907-441-4569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1444
License Number StateWY

VIII. Authorized Official

Name: TODD S CHRISTENSEN
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 907-441-4569