Organization
EVERGREEN DENTAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. RACHAEL FETUAO MIDDLETON (CHIEF OPERATIONS OFFICER)
(907) 276-4537
Entity
Organization
Contact information
Practice address
125 W EVERGREEN AVE STE 204, PALMER, AK 99645-6908
(907) 531-3477
Mailing address
125 W EVERGREEN AVE STE 204, PALMER, AK 99645-6908
(907) 531-3477
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1417158080
—
AK
05
—
1922430040
—
AK
Enumeration date
09/29/2020
Last updated
09/29/2020
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