Healthcare Provider Details

I. General information

NPI: 1619960440
Provider Name (Legal Business Name): G FRIEND DDS MS & M WILSON DDS MS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 ALLYSON LANE
CONWAY AR
72034
US

IV. Provider business mailing address

PO BOX 11020
CONWAY AR
72034-0018
US

V. Phone/Fax

Practice location:
  • Phone: 501-730-0375
  • Fax: 501-730-0335
Mailing address:
  • Phone: 501-730-0375
  • Fax: 501-730-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2793
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2817
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3475
License Number StateAR

VIII. Authorized Official

Name: DR. GERALD W FRIEND
Title or Position: OWNER
Credential: DDS MS
Phone: 501-730-0375