Healthcare Provider Details

I. General information

NPI: 1649446162
Provider Name (Legal Business Name): MAXILLOFACIAL SURGERY CENTER OF CENTRAL ARKANSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WESTERN AVE STE 204
CONWAY AR
72034-4980
US

IV. Provider business mailing address

525 WESTERN AVE STE 204
CONWAY AR
72034-4980
US

V. Phone/Fax

Practice location:
  • Phone: 501-336-8888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3079
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberN8414
License Number StateAR

VIII. Authorized Official

Name: DR. MITCH L MITCHELL
Title or Position: OWNER
Credential: M.D., D.D.S.
Phone: 501-336-8888