MEDICARE: ARKLATEX FAMILY DENTAL CENTER

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	122300000X	Dentist

General Provider Information

NPI Number	:	1699960526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARKLATEX FAMILY DENTAL CENTER

Provider Business Mailing Address
First Line	:	421 PECAN ST
Second Line	:
City	:	TEXARKANA
State	:	AR
Zip	:	71854-5333
Country	:	US
Telephone Number	:	870-779-0411
Fax Number	:

Provider Business Practice Location Address
First Line	:	421 PECAN ST
Second Line	:
City	:	TEXARKANA
State	:	AR
Zip	:	71854-5333
Country	:	US
Telephone Number	:	870-779-0411
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. SCOTT JOLLY
Credential	:	DDS
Telephone Number	:	870-779-0411

Provider Enumeration Date	:	09/13/2007
Last Update Date	:	09/13/2007

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Directions to “ARKLATEX FAMILY DENTAL CENTER ” Practice Location

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