Healthcare Provider Details

I. General information

NPI: 1225325731
Provider Name (Legal Business Name): TATUM ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 N MAIN ST
HARRISON AR
72601-2914
US

IV. Provider business mailing address

823 N MAIN ST STE 6
HARRISON AR
72601-2914
US

V. Phone/Fax

Practice location:
  • Phone: 870-204-6555
  • Fax:
Mailing address:
  • Phone: 870-204-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number125
License Number StateAR

VIII. Authorized Official

Name: DR. ANNAKATE MILBURN TATUM
Title or Position: SOLE MEMBER
Credential: DDS
Phone: 870-204-6555