=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962778001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMER DENTAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2012
-----------------------------------------------------
Last Update Date | 03/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4014 LAKE ST. STE 210
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-235-7585
-----------------------------------------------------
Fax | 907-235-7311
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4014 LAKE ST. STE. 210
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-235-7585
-----------------------------------------------------
Fax | 907-235-7311
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. VICKEY J. HODNIK
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 907-235-7585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 692
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------