NPIMap

Organization Active NPI

Southcentral Foundation

Doing business as Dental- Indian Creek Dental Clinic

  • General Practice Dentistry
  • Tyonek, AK
National Provider Identifier
1659828556
Registry record updated Sep 14, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
20467 Issued in AK
Legal business name
SOUTHCENTRAL FOUNDATION
Doing business as
Dental- Indian Creek Dental Clinic
Practice address
101 Indian Creek Road
Tyonek, AK 99682
Phone
(907) 583-2461
NPI assigned
Sep 8, 2016
Last updated
Sep 14, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
SOUTHCENTRAL FOUNDATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 14, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ronald Lee Olson
Title
Executive Vice President Finance
Phone
(907) 729-4939

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X 20467 AK Primary

Addresses

Primary practice location

101 Indian Creek Road
Tyonek, AK 99682

Mailing address

PO Box 35151
Seattle, WA 98124-5151

Other identifiers 1

IdentifierTypeStateIssuer
1654559MedicaidAK

Other names 1

  • Dental- Indian Creek Dental Clinic Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Southcentral Foundation PDN103 organizations share this tax ID, including this one
Part of
Southcentral Foundation PDN

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1473292800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694649600000",
    "number": "1659828556",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 35151",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981245151"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 INDIAN CREEK ROAD",
            "city": "TYONEK",
            "state": "AK",
            "postal_code": "99682",
            "telephone_number": "907-583-2461"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHCENTRAL FOUNDATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHCENTRAL FOUNDATION",
        "enumeration_date": "2016-09-08",
        "last_updated": "2023-09-14",
        "certification_date": "2023-09-14",
        "status": "A",
        "authorized_official_last_name": "OLSON",
        "authorized_official_first_name": "RONALD",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "EXECUTIVE VICE PRESIDENT FINANCE",
        "authorized_official_telephone_number": "907-729-4939"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "AK",
            "license": "20467",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1654559",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dental- Indian Creek Dental Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tyonek, AK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 14, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.