1619133279 NPI number — MAUMELLE FAMILY DENTAL CARE

Table of content: (NPI 1619133279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619133279 NPI number — MAUMELLE FAMILY DENTAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAUMELLE FAMILY DENTAL CARE
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:
6
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:
1619133279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 MILLWOOD CIR
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
MAUMELLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72113-6319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-851-7645
Provider Business Mailing Address Fax Number:
501-851-4281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MILLWOOD CIR
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MAUMELLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72113-6319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-851-7645
Provider Business Practice Location Address Fax Number:
501-851-4281
Provider Enumeration Date:
08/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
GENERAL DENTIST
Authorized Official Telephone Number:
501-851-7645

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2648 , 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: 5T895 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 975050 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 995157 . This is a "COMPBENEFITS" identifier . This identifiers is of the category "OTHER".




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