Basic Information
| Provider Information | |||||||||
| NPI: | 1831206226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPRAGUE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 567 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077723320 | ||||||||
| FaxNumber: | 9077723320 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 W EXCEL | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077723320 | ||||||||
| FaxNumber: | 9077723320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | AA367 | AK | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DDO 367 | 05 | AK | MEDICAID | AA367 | 01 | AK | STATE LICENSE NUMBER | OTHER |