1508889478 NPI number — G FRIEND DDS MS & M WILSON DDS MS PA

Table of content: (NPI 1508889478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508889478 NPI number — G FRIEND DDS MS & M WILSON DDS MS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G FRIEND DDS MS & M WILSON DDS MS PA
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:
NORTH LITTLE ROCK PEDIATRIC DENTAL GROUP
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:
1508889478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4605 FAIRWAY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-771-2990
Provider Business Mailing Address Fax Number:
501-753-0408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4605 FAIRWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-771-2990
Provider Business Practice Location Address Fax Number:
501-758-0408
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
501-771-2990

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  2817 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 2793 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: 2700 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5B771 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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