Healthcare Provider Details

I. General information

NPI: 1154117463
Provider Name (Legal Business Name): PREMIER DERMATOLOGY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 SE PLAZA AVE STE 5
BENTONVILLE AR
72712-5473
US

IV. Provider business mailing address

901 SE PLAZA AVE STE 5
BENTONVILLE AR
72712-5473
US

V. Phone/Fax

Practice location:
  • Phone: 479-273-3376
  • Fax: 479-273-3468
Mailing address:
  • Phone: 479-273-3376
  • Fax: 479-273-3468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SARA FAST
Title or Position: PRACTICE DIRECTOR
Credential:
Phone: 479-876-8501