1770755118 NPI number — DR. LARKIN MONROE WILSON III DDS

Table of content: DR. LARKIN MONROE WILSON III DDS (NPI 1770755118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770755118 NPI number — DR. LARKIN MONROE WILSON III DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
LARKIN
Provider Middle Name:
MONROE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1770755118
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 MT HOLLY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL DORADO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-862-8090
Provider Business Mailing Address Fax Number:
870-862-0403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MOUNT HOLLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL DORADO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71730-4542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-862-8090
Provider Business Practice Location Address Fax Number:
870-862-0403
Provider Enumeration Date:
03/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2894 , 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)





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