1790909752 NPI number — KEN WOOD, D.D.S. M.S. CHILDRENS DENTISTRY

Table of content: (NPI 1790909752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790909752 NPI number — KEN WOOD, D.D.S. M.S. CHILDRENS DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEN WOOD, D.D.S. M.S. CHILDRENS DENTISTRY
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:
1790909752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72403-1369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-931-5437
Provider Business Mailing Address Fax Number:
870-931-9781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2702 S CULBERHOUSE ST
Provider Second Line Business Practice Location Address:
SUITE Q
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-7132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-931-5437
Provider Business Practice Location Address Fax Number:
870-931-9781
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
I
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
870-931-5437

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  2738 , 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: 828134 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 59239 . This is a "ARKANSAS BLUE CROSS BLUE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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