Basic Information
Provider Information | |||||||||
NPI: | 1386670446 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PREWITT | ||||||||
FirstName: | ANITA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.D.H. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 904 LES ROGERS TURNAROUND | ||||||||
Address2: |   | ||||||||
City: | NORTH POLE | ||||||||
State: | AK | ||||||||
PostalCode: | 997057635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074884392 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1060 GAFFNEY RD | ||||||||
Address2: |   | ||||||||
City: | FORT WAINWRIGHT | ||||||||
State: | AK | ||||||||
PostalCode: | 997035002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9073535530 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 712 | AK | Y |   | Dental Providers | Dental Hygienist |   |
ID Information
ID | Type | State | Issuer | Description | 540 | 01 | AK | LOCAL ANETHSTETIC AGENTS | OTHER |