1528663879 NPI number — EMMALEE BEENE-GREGORY DDS

Table of content: (NPI 1528663879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528663879 NPI number — EMMALEE BEENE-GREGORY DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMMALEE BEENE-GREGORY DDS
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:
1528663879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 432
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAGNOLIA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71754-0432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-234-5244
Provider Business Mailing Address Fax Number:
870-234-7504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1018 N WASHINGTON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAGNOLIA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71753-2456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-234-5244
Provider Business Practice Location Address Fax Number:
870-234-7504
Provider Enumeration Date:
12/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BEENE-GREGORY
Authorized Official First Name:
EMMALEE
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
870-234-5244

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)

  • Identifier: 120909608 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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