=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003280991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOOKHART DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2015
-----------------------------------------------------
Last Update Date | 11/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18932 TWENTY GRAND RD
-----------------------------------------------------
City | EAGLE RIVER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99577-8397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-484-9282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18932 TWENTY GRAND RD
-----------------------------------------------------
City | EAGLE RIVER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99577-8397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-484-9282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SETH LOOKHART
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 208-484-9282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1007485
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------