Provider Demographics
NPI:1306987532
Name:COPPER RIVER NATIVE ASSOCIATION
Entity type:Organization
Organization Name:COPPER RIVER NATIVE ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILTS JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-822-5241
Mailing Address - Street 1:187 GLENN HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:GLENNALLEN
Mailing Address - State:AK
Mailing Address - Zip Code:99588-0744
Mailing Address - Country:US
Mailing Address - Phone:907-822-3113
Mailing Address - Fax:907-822-4045
Practice Address - Street 1:GLENN HWY. 187 MP
Practice Address - Street 2:
Practice Address - City:GLENNALLEN
Practice Address - State:AK
Practice Address - Zip Code:99588-0744
Practice Address - Country:US
Practice Address - Phone:907-822-3113
Practice Address - Fax:907-822-4045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK36087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDD1001Medicaid