Basic Information
| Provider Information | |||||||||
| NPI: | 1316147069 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHUGACHMIUT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NORTH STAR DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1840 BRAGAW ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995083463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075624155 | ||||||||
| FaxNumber: | 9075632891 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 3RD AVENUE SUITE 115 | ||||||||
| Address2: | |||||||||
| City: | SEWARD | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072244925 | ||||||||
| FaxNumber: | 9072244933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | KELLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH SERVICES DIVISION DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9075624155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHUGACHMIUT | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 1003824 | 05 | AK | MEDICAID |