=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891248118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUCILLE DENTAL,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2016
-----------------------------------------------------
Last Update Date | 08/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 E SWANSON AVE
-----------------------------------------------------
City | WASILLA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99654-7024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-376-5207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 E SWANSON AVE
-----------------------------------------------------
City | WASILLA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99654-7024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-376-5207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | KRIS P GURR
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 480-353-0027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1040252
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------