Provider Demographics
NPI:1043578255
Name:PRIEBE ORTHODONTICS, PC
Entity type:Organization
Organization Name:PRIEBE ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:N
Authorized Official - Last Name:PRIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-563-2828
Mailing Address - Street 1:10998 O'MALLEY CENTRE DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-3069
Mailing Address - Country:US
Mailing Address - Phone:907-563-2828
Mailing Address - Fax:
Practice Address - Street 1:10998 O'MALLEY CENTRE DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3069
Practice Address - Country:US
Practice Address - Phone:907-563-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1089.131122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty