MEDICARE: MOOSE'S TOOTH CHILDREN'S DENTISTRY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1639666530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOOSE'S TOOTH CHILDREN'S DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	114 MINNIE ST STE A
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99701-3000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	167 S SANTA CLAUS LN STE B
Second Line	:
City	:	NORTH POLE
State	:	AK
Zip	:	99705-7755
Country	:	US
Telephone Number	:	907-268-6644
Fax Number	:	907-268-6670

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. DALLIN YOUNG
Credential	:	DDS
Telephone Number	:	208-404-9888

Provider Enumeration Date	:	04/16/2018
Last Update Date	:	04/16/2018

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