Healthcare Provider Details

I. General information

NPI: 1336376847
Provider Name (Legal Business Name): ANNAKATE MILBURN TATUM D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

825 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 Number3808
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8774
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: