1083869911 NPI number — WEEKEND DENTAL CLINIC

Table of content: (NPI 1083869911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083869911 NPI number — WEEKEND DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEEKEND DENTAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHARLES G. LIGGETT, JR. DDS, PLLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083869911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 ROGERS AVE
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72903-2954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-782-0080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5111 ROGERS AVE
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-2047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-719-0753
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LIGGETT
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-719-0753

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3478 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 152884608 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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