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General NPI Number Information
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NPI Number | 1841580966
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Entity Type | Organization
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Legal Business Name | SOUTH ANCHORAGE DENTAL CENTER
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Dates
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Enumeration Date | 04/11/2011
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Last Update Date | 04/11/2011
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Provider Practice Location Address
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Address Line | 9170 JEWEL LAKE RD STE 201
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City | ANCHORAGE
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State | AK
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Zip | 99502-5390
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Country | US
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Telephone | 907-248-7275
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Fax | 907-248-7221
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Provider Business Mailing Address
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Address Line | 9170 JEWEL LAKE RD STE 201
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City | ANCHORAGE
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State | AK
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Zip | 99502-5390
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Country | US
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Telephone | 907-248-7275
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Fax | 907-248-7221
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Authorized Official
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Title or Position | DENTIST
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Name | BROC WAYNE BRIMHALL
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Credential | DMD
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Telephone | 907-248-7275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 1308
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License Number State | AK
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