MEDICARE: DR. DAVID LEE SULKOSKY DDS

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	1223G0001X	General Practice Dentistry	452	AK

General Provider Information

NPI Number	:	1659563757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID LEE SULKOSKY DDS

Provider Business Mailing Address
First Line	:	PO BOX 80388
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99708-0388
Country	:	US
Telephone Number	:	907-374-0404
Fax Number	:	907-374-0404

Provider Business Practice Location Address
First Line	:	1325 WAKE FOREST WAY
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99709-3224
Country	:	US
Telephone Number	:	907-374-0404
Fax Number	:	907-374-0404

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	08/13/2007

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