Provider Demographics
NPI:1962778001
Name:HOMER DENTAL CENTER INC
Entity type:Organization
Organization Name:HOMER DENTAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HODNIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-235-7585
Mailing Address - Street 1:4014 LAKE ST.
Mailing Address - Street 2:STE. 210
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603
Mailing Address - Country:US
Mailing Address - Phone:907-235-7585
Mailing Address - Fax:907-235-7311
Practice Address - Street 1:4014 LAKE ST.
Practice Address - Street 2:STE 210
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-235-7585
Practice Address - Fax:907-235-7311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOMER DENTAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty