Provider Demographics
NPI:1124244181
Name:INTERIOR COMMUNITY HEALTH CENTER DENTAL PROG
Entity type:Organization
Organization Name:INTERIOR COMMUNITY HEALTH CENTER DENTAL PROG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-455-4567
Mailing Address - Street 1:1606 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6407
Mailing Address - Country:US
Mailing Address - Phone:907-455-4567
Mailing Address - Fax:
Practice Address - Street 1:1606 23RD AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6407
Practice Address - Country:US
Practice Address - Phone:907-455-4567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK02-1810OtherPROVIDER NUMBER