Provider Demographics
NPI:1194875393
Name:ALASKA DENTAL GROUP P.C.
Entity type:Organization
Organization Name:ALASKA DENTAL GROUP P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-562-6648
Mailing Address - Street 1:3340 PROVIDENCE DR STE 560
Mailing Address - Street 2:PROVIDENCE MEDICAL OFFICE BLDG.
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4643
Mailing Address - Country:US
Mailing Address - Phone:907-562-6648
Mailing Address - Fax:907-561-8385
Practice Address - Street 1:3340 PROVIDENCE DR STE 560
Practice Address - Street 2:PROVIDENCE MEDICAL OFFICE BLDG.
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4643
Practice Address - Country:US
Practice Address - Phone:907-562-6648
Practice Address - Fax:907-561-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4367331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK826322OtherUNITED CONCORDIA
AKDD0888Medicaid