=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003539008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AESTHETIC DENTAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2022
-----------------------------------------------------
Last Update Date | 09/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 W PARKS HWY
-----------------------------------------------------
City | WASILLA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99654-6933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-357-6684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10928 EAGLE RIVER RD
-----------------------------------------------------
City | EAGLE RIVER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99577-8078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-622-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | AMANDA HARRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-229-2228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------