=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235011834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS N WANAT III, DMD, MSD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2025
-----------------------------------------------------
Last Update Date | 07/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 ABBOTT RD STE 5
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99507-4624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-313-8918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 ABBOTT RD STE 5
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99507-4624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-313-8918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PERIODONTIST
-----------------------------------------------------
Name | DR. THOMAS NELSON WANAT III
-----------------------------------------------------
Credential | DMD, MSD
-----------------------------------------------------
Telephone | 907-313-8918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------