1316234636 NPI number — SMILES OF ARKANSAS DENTAL CENTER, 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 1316234636 NPI number — SMILES OF ARKANSAS DENTAL CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILES OF ARKANSAS DENTAL CENTER, 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:
TEXARKANA DIVISION
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:
1316234636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1621 ARKANSAS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71854-1607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-774-7645
Provider Business Mailing Address Fax Number:
870-773-7647

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1621 ARKANSAS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71854-1607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-774-7645
Provider Business Practice Location Address Fax Number:
870-773-7647
Provider Enumeration Date:
07/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KOGER
Authorized Official First Name:
JODIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
870-777-6453

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3177 , 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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