Provider Demographics
NPI:1447486402
Name:UNIVERSITY DENTAL CENTER
Entity type:Organization
Organization Name:UNIVERSITY DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BAST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-479-2206
Mailing Address - Street 1:570 UNIVERSITY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3641
Mailing Address - Country:US
Mailing Address - Phone:907-479-2206
Mailing Address - Fax:907-479-6847
Practice Address - Street 1:570 UNIVERSITY AVE STE A
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3641
Practice Address - Country:US
Practice Address - Phone:907-479-2206
Practice Address - Fax:907-479-6847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty