Healthcare Provider Details

I. General information

NPI: 1003194317
Provider Name (Legal Business Name): FERGUS ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OSLER DRIVE SUITE D
JONESBORO AR
72401
US

IV. Provider business mailing address

801 OSLER DRIVE SUITE D
JONESBORO AR
72401
US

V. Phone/Fax

Practice location:
  • Phone: 870-336-3366
  • Fax: 870-336-3366
Mailing address:
  • Phone: 870-336-3366
  • Fax: 870-336-3366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number115
License Number StateAR

VIII. Authorized Official

Name: KELLY GWYNNE MASON FERGUS
Title or Position: SOLE MBR
Credential: DDS,MS
Phone: 870-336-3366