Organization
SOUTHCENTRAL FOUNDATION
Active
Parent organization
SOUTHCENTRAL FOUNDATION
Other names
Dental- Nilavena Dental Clinic
Organization subpart
Yes
Provider details
NPI number
Legal business name
SOUTHCENTRAL FOUNDATION
Authorized official
RONALD LEE OLSON (EXECUTIVE VICE PRESIDENT FINANCE)
(907) 729-4939
Entity
Organization
Contact information
Practice address
101 AIRPORT ROAD, ILIAMNA, AK 99606
(907) 571-1818
Mailing address
PO BOX 35151, SEATTLE, WA 98124-5151
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
—
—
125J00000X
Dental Therapist
—
—
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1654555
—
AK
Enumeration date
04/12/2021
Last updated
09/15/2023
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