Active NPI
Derick Jack Sovereign, DMD
- Dentist
- Wasilla, AK
National Provider Identifier
1245073287
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 224623
- Practice address
- 3765 E Blue Lupine Dr Ste a
Wasilla, AK 99654-8417 - Phone
- (480) 341-0791
- NPI assigned
- Jun 17, 2024
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 224623 | AK | Primary |
Addresses
Primary practice location
3765 E Blue Lupine Dr Ste a
Wasilla, AK 99654-8417
Mailing address
3765 E Blue Lupine Dr Ste a
Wasilla, AK 99654-8417
Phone (480) 341-0791
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 224623 | AK | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1718582400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1718582400000",
"number": "1245073287",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3765 E BLUE LUPINE DR STE A",
"city": "WASILLA",
"state": "AK",
"postal_code": "996548417",
"telephone_number": "480-341-0791"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3765 E BLUE LUPINE DR STE A",
"city": "WASILLA",
"state": "AK",
"postal_code": "996548417",
"telephone_number": "480-341-0791"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SOVEREIGN",
"first_name": "DERICK",
"middle_name": "JACK",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2024-06-17",
"last_updated": "2024-06-17",
"certification_date": "2024-06-17",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "AK",
"license": "224623",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Wasilla, AK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.