Healthcare Provider Details

I. General information

NPI: 1417797176
Provider Name (Legal Business Name): ANDREW PLICHTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 S AMITY RD
CONWAY AR
72032-8090
US

IV. Provider business mailing address

6775 CROWN DR
BROWNSBURG IN
46112-9100
US

V. Phone/Fax

Practice location:
  • Phone: 501-764-4465
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.027573
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4841
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: