Healthcare Provider Details

I. General information

NPI: 1558538181
Provider Name (Legal Business Name): ARKANSAS DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 GATEWAY COVE
JONESBORO AR
72404
US

IV. Provider business mailing address

3409 GATEWAY COVE
JONESBORO AR
72404
US

V. Phone/Fax

Practice location:
  • Phone: 870-336-0543
  • Fax:
Mailing address:
  • Phone: 870-336-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2621
License Number StateAR

VIII. Authorized Official

Name: MRS. DIANE SECREASE
Title or Position: OFFICE MANAGER
Credential: RDA CDA
Phone: 870-932-0330