Petersburg Dental, Inc.

Primary specialty

DentistTaxonomy code 122300000X

License

1096 Issued in AK

Legal business name

PETERSBURG DENTAL, INC.

Practice address

806 S. Nordic Dr.
Petersburg, AK 99833-0469

Phone

(907) 772-9246

Fax

(907) 772-9278

NPI assigned

Apr 29, 2013

Last updated

Apr 29, 2013By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Jay Lister

Title

DDS/President

Phone

(907) 772-9246

Specialties & licenses 1

Addresses

Other identifiers 1

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Philip Gaither Beardslee, DMD

  • General Practice Dentistry
  • Petersburg, AK
  • NPI 1326260621
  NPD (past)
• David Arnold Spencer, DDS

  • General Practice Dentistry
  • Petersburg, AK
  • NPI 1114143203
  NPD (past)

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

{
    "created_epoch": "1367193600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1367193600000",
    "number": "1932543345",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 469",
            "city": "PETERSBURG",
            "state": "AK",
            "postal_code": "998330469",
            "telephone_number": "907-772-9246",
            "fax_number": "907-772-9278"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "806 S. NORDIC DR.",
            "city": "PETERSBURG",
            "state": "AK",
            "postal_code": "998330469",
            "telephone_number": "907-772-9246",
            "fax_number": "907-772-9278"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETERSBURG DENTAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-04-29",
        "last_updated": "2013-04-29",
        "status": "A",
        "authorized_official_last_name": "LISTER",
        "authorized_official_first_name": "JAY",
        "authorized_official_title_or_position": "DDS/PRESIDENT",
        "authorized_official_telephone_number": "907-772-9246"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "AK",
            "license": "1096",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "DD54042",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Derrick Glen Osoup
• Pacific Northwest Radiology LLC
• Pacific Wings, LLC
• Petersburg Borough
• Petersburg Borough
• Petersburg Medical Center
• Petersburg Medical Center
• Petersburg Medical Center
• Petersburg Mental Health Services
• Petersburg Mental Health Services, Inc.

• Dentist in Petersburg, AK
• Providers in Petersburg, AK by specialty
• Dentist in Alaska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2013; 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.