Healthcare Provider Details

I. General information

NPI: 1548681885
Provider Name (Legal Business Name): DEQUEEN DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1347 W COLLIN RAYE DR
DE QUEEN AR
71832-2946
US

IV. Provider business mailing address

1347 W COLLIN RAYE DR
DE QUEEN AR
71832-2946
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-5034
  • Fax: 870-642-2365
Mailing address:
  • Phone: 870-642-5034
  • Fax: 870-642-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3669
License Number StateAR

VIII. Authorized Official

Name: DR. CHRISTIE JAQUESS
Title or Position: PHYSICIAN
Credential: D.D.S.
Phone: 870-642-5034