Basic Information
| Provider Information | |||||||||
| NPI: | 1073645818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERRERO | ||||||||
| FirstName: | ELMER | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUERRERO | ||||||||
| OtherFirstName: | ELMER | ||||||||
| OtherMiddleName: | JOSEPH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2960 TONGASS AVE | ||||||||
| Address2: | SUITE #403 | ||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072284902 | ||||||||
| FaxNumber: | 9072285256 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 TONGASS AVE | ||||||||
| Address2: | SUITE #403 | ||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072284902 | ||||||||
| FaxNumber: | 9072285256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 941 | AK | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | DD0941 | 05 | AK | MEDICAID |