Healthcare Provider Details

I. General information

NPI: 1043609522
Provider Name (Legal Business Name): BRACES OF THE OZARKS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 N MAIN ST SUITE 6
HARRISON AR
72601-2914
US

IV. Provider business mailing address

5100 TALLEY RD SUITE 100
LITTLE ROCK AR
72204-8032
US

V. Phone/Fax

Practice location:
  • Phone: 501-781-2777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2681
License Number StateAR

VIII. Authorized Official

Name: DR. MARK DAKE
Title or Position: OWNER
Credential:
Phone: 501-781-2777