Provider Demographics
NPI:1962779405
Name:CADZOW, CORRINA LYNN (11-070-DHAT)
Entity type:Individual
Prefix:
First Name:CORRINA
Middle Name:LYNN
Last Name:CADZOW
Suffix:
Gender:F
Credentials:11-070-DHAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:FORT YUKON
Mailing Address - State:AK
Mailing Address - Zip Code:99740-0309
Mailing Address - Country:US
Mailing Address - Phone:907-662-2460
Mailing Address - Fax:907-662-2709
Practice Address - Street 1:EAST 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT YUKON
Practice Address - State:AK
Practice Address - Zip Code:99740
Practice Address - Country:US
Practice Address - Phone:907-662-2460
Practice Address - Fax:907-662-2709
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11-070-DHAT247200000X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK11-070-DHATMedicaid