Provider Demographics
NPI:1104996214
Name:FAMILY MEDICAL DENTAL CENTER OF ALASKA INC
Entity type:Organization
Organization Name:FAMILY MEDICAL DENTAL CENTER OF ALASKA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELEDATH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOPINATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-869-2238
Mailing Address - Street 1:PO BOX 210549
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99521-0549
Mailing Address - Country:US
Mailing Address - Phone:907-333-1211
Mailing Address - Fax:
Practice Address - Street 1:4361 BONIFACE PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4316
Practice Address - Country:US
Practice Address - Phone:907-333-1211
Practice Address - Fax:907-333-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK293681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK29368OtherSTATE LICENSE