Provider Demographics
NPI:1689816969
Name:HANS P. NORDSTROM DDS
Entity type:Organization
Organization Name:HANS P. NORDSTROM DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANS
Authorized Official - Middle Name:P
Authorized Official - Last Name:NORDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-357-6800
Mailing Address - Street 1:1001 E. USA CIRCLE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7198
Mailing Address - Country:US
Mailing Address - Phone:907-357-6800
Mailing Address - Fax:907-357-6878
Practice Address - Street 1:1001 E. USA CIRCLE
Practice Address - Street 2:SUITE B
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7198
Practice Address - Country:US
Practice Address - Phone:907-357-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01634756OtherUNITED CONCORDIA
AKDD53521Medicaid