Provider Demographics
NPI:1063541886
Name:SARGENT, JOHN W (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:SARGENT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 AIRPORT WAY
Mailing Address - Street 2:STE #1
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-452-1250
Mailing Address - Fax:907-456-1307
Practice Address - Street 1:3112 AIRPORT WAY
Practice Address - Street 2:STE #1
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-452-1250
Practice Address - Fax:907-456-1307
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK298122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK000783712OtherUNITED CONCORDIA
AKDD0298Medicaid