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General NPI Number Information
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NPI Number | 1629214705
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Entity Type | Organization
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Legal Business Name | EAGLE SUMMIT DENTAL GROUP
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Dates
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Enumeration Date | 12/19/2008
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Last Update Date | 11/25/2014
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Provider Practice Location Address
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Address Line | 13015 OLD GLENN HWY #200
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City | EAGLE RIVER
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State | AK
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Zip | 99577
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Country | US
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Telephone | 907-694-8234
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Fax | 907-697-8225
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Provider Business Mailing Address
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Address Line | 13015 OLD GLENN HWY #200
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City | EAGLE RIVER
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State | AK
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Zip | 99577-8080
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Country | US
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Telephone | 907-694-8234
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Fax | 907-697-8225
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL ROLAND SANDERS
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Credential | DMD
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Telephone | 907-694-8234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1086
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License Number State | AK
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