MEDICARE: CARL CODY FRIDDLE, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3558	AR

General Provider Information

NPI Number	:	1376729095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARL CODY FRIDDLE, PLLC

Provider Business Mailing Address
First Line	:	5008 S U ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3613
Country	:	US
Telephone Number	:	479-452-8800
Fax Number	:	479-452-6926

Provider Business Practice Location Address
First Line	:	5008 S U ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3613
Country	:	US
Telephone Number	:	479-452-8800
Fax Number	:	479-452-6926

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CARL CODY FRIDDLE
Credential	:	DDS
Telephone Number	:	479-452-8800

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	01/11/2008

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