Basic Information
| Provider Information | |||||||||
| NPI: | 1508902529 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH EAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEARHC HAINES DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634074 | ||||||||
| FaxNumber: | 9074631510 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 DALTON STREET | ||||||||
| Address2: | STE 102 | ||||||||
| City: | HAINES | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998279982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077666372 | ||||||||
| FaxNumber: | 9077662581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. VP / CFO | ||||||||
| AuthorizedOfficialTelephone: | 9074634000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 70206 | AK | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1003869 | 05 | AK | MEDICAID |