1023349651 NPI number — MAMMOTH SPRING DENTAL CLINIC, LLC

Table of content: (NPI 1023349651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023349651 NPI number — MAMMOTH SPRING DENTAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAMMOTH SPRING DENTAL CLINIC, LLC
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:
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:
1023349651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAMMOTH SPRING
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-625-3262
Provider Business Mailing Address Fax Number:
870-625-3673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAMMOTH SPRING
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-625-3262
Provider Business Practice Location Address Fax Number:
870-625-3673
Provider Enumeration Date:
01/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KERSEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
870-625-3262

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2661 , 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: 402069306 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 889-284 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 56593 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 102276608 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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