1417159427 NPI number — ARKANSAS DENTAL CENTER

Table of content: (NPI 1417159427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417159427 NPI number — ARKANSAS DENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARKANSAS DENTAL CENTER
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:
ARKANSAS DENTAL CENTER
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:
1417159427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 W COMMERCE ST
Provider Second Line Business Mailing Address:
SUITE ONE
Provider Business Mailing Address City Name:
BRYANT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72022-7514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-847-9191
Provider Business Mailing Address Fax Number:
501-847-8337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 W COMMERCE ST
Provider Second Line Business Practice Location Address:
SUITE ONE
Provider Business Practice Location Address City Name:
BRYANT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72022-7514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-847-9191
Provider Business Practice Location Address Fax Number:
501-847-8337
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COBB
Authorized Official First Name:
ANDY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
501-847-9191

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3065 , 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: 5T579 . This is a "ABCBS PROVIDER NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 1174534804 . This is a "NATIONAL PROVIDER IDENTIF" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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