1508454612 NPI number — PRAIRIE GROVE DENTAL CENTER PLLC

Table of content: (NPI 1508454612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508454612 NPI number — PRAIRIE GROVE DENTAL CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE GROVE 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:
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:
1508454612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1121 E HERITAGE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRAIRIE GROVE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72753-6013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-244-2052
Provider Business Mailing Address Fax Number:
479-846-1940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 E HERITAGE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRAIRIE GROVE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72753-6013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-244-2052
Provider Business Practice Location Address Fax Number:
479-846-1940
Provider Enumeration Date:
01/05/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
DENTIST-OWNER
Authorized Official Telephone Number:
479-244-2052

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com