Healthcare Provider Details

I. General information

NPI: 1710052279
Provider Name (Legal Business Name): WARREN COLEMAN MASSEY D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3089 E MISSION BLVD
FAYETTEVILLE AR
72703-4385
US

IV. Provider business mailing address

3089 E MISSION BLVD
FAYETTEVILLE AR
72703-4385
US

V. Phone/Fax

Practice location:
  • Phone: 479-442-6995
  • Fax: 449-443-6468
Mailing address:
  • Phone: 479-442-6995
  • Fax: 449-443-6468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2059
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: