Healthcare Provider Details

I. General information

NPI: 1881096519
Provider Name (Legal Business Name): AR PERIODONTAL & IMPLANT ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 N GREEN ACRES RD
FAYETTEVILLE AR
72703-2619
US

IV. Provider business mailing address

3800 ROGERS AVE SUITE 3
FORT SMITH AR
72903-3046
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-6400
  • Fax: 479-521-0164
Mailing address:
  • Phone: 479-785-4848
  • Fax: 479-785-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3262
License Number StateAR

VIII. Authorized Official

Name: MRS. CINDY KAY RABEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 479-521-6400