1306531587 NPI number — CRICKET DENTAL PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306531587 NPI number — CRICKET DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRICKET DENTAL PLLC
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:
1306531587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 BIRNAMWOOD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORREST CITY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72335-2415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-821-9212
Provider Business Mailing Address Fax Number:
870-633-8460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 PORTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HELENA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72342-3216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-633-4591
Provider Business Practice Location Address Fax Number:
870-633-8460
Provider Enumeration Date:
04/05/2023

Additional Information

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
CAITLIN
Authorized Official Middle Name:
KERN
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
870-821-9212

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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