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General NPI Number Information
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NPI Number | 1780706838
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Entity Type | Organization
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Legal Business Name | SOUTHEAST DENTAL GROUP, PC
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 02/04/2014
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Provider Practice Location Address
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Address Line | 2220 DUNN ST
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City | JUNEAU
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State | AK
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Zip | 99801-1430
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Country | US
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Telephone | 907-586-9885
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Fax | 907-586-1849
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Provider Business Mailing Address
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Address Line | 2220 DUNN ST
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City | JUNEAU
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State | AK
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Zip | 99801-9304
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Country | US
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Telephone | 907-586-9885
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Fax | 907-586-1849
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Authorized Official
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Title or Position | DENTIST VICE PRESIDENT
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Name | DR. KRISTEN J SCHULTZ
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Credential | D.D.S.
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Telephone | 907-586-9885
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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 | 7435
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7113
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 961
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License Number State | AK
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 963
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License Number State | AK
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