Basic Information
Provider Information
NPI: 1033556527
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: DENNIS
MiddleName: GRAY
NamePrefix: DR.
NameSuffix:  
Credential: PTA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3801 UNIVERSITY LAKE DR
Address2: SUITE 200
City: ANCHORAGE
State: AK
PostalCode: 995084639
CountryCode: US
TelephoneNumber: 9075618681
FaxNumber:  
Practice Location
Address1: 6310 HABICHT CT
Address2:  
City: ANCHORAGE
State: AK
PostalCode: 995041063
CountryCode: US
TelephoneNumber: 9072762531
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/24/2013
LastUpdateDate: 05/24/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QP2000X834AKY Ambulatory Health Care FacilitiesClinic/CenterPhysical Therapy

No ID Information.


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