Provider Demographics
NPI:1144341660
Name:MCLEAN, JILL KATHRYN (DDS)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:KATHRYN
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MCLEAN
Other - Last Name:CALVERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:BOX 525
Mailing Address - Street 2:DENTAL DEPT
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:98862
Mailing Address - Country:US
Mailing Address - Phone:907-543-6229
Mailing Address - Fax:
Practice Address - Street 1:829 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:98862
Practice Address - Country:US
Practice Address - Phone:907-543-6229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-08-10
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-10
Provider Licenses
StateLicense IDTaxonomies
AKDD5790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD5790Medicaid