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General NPI Number Information
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NPI Number | 1578999306
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Entity Type | Organization
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Legal Business Name | KEGUTA DENTAL LLC
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Dates
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Enumeration Date | 09/25/2013
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Last Update Date | 08/20/2014
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Provider Practice Location Address
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Address Line | 660 THIRD AVE STE C
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City | BETHEL
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State | AK
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Zip | 99559-0169
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Country | US
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Telephone | 907-545-3996
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1051
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City | STERLING
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State | AK
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Zip | 99672-1051
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Country | US
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Telephone | 206-419-0787
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Fax |
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Authorized Official
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Title or Position | DENTAL DIRECTOR/MANAGER
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Name | EDWIN H ALLGAIR JR.
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Credential | DDS
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Telephone | 206-419-0787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D997
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License Number State | AK
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