Healthcare Provider Details

I. General information

NPI: 1922292531
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF EASTERN ARKANSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4941 N WASHINGTON HWY 1
FORREST CITY AR
72335-3022
US

IV. Provider business mailing address

4941 N WASHINGTON HIGHWAY 1
FORREST CITY AR
72335-3022
US

V. Phone/Fax

Practice location:
  • Phone: 870-630-1500
  • Fax: 870-630-6405
Mailing address:
  • Phone: 870-630-1500
  • Fax: 870-630-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3045
License Number StateAR

VIII. Authorized Official

Name: SHAORN RAE FRANKS
Title or Position: RDA/OFFICE MANAGER
Credential: RDA
Phone: 870-630-1500