Healthcare Provider Details

I. General information

NPI: 1881053361
Provider Name (Legal Business Name): AXPM SW LITTLE ROCK PEDO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 GEYER SPRINGS RD
LITTLE ROCK AR
72209-6425
US

IV. Provider business mailing address

PO BOX 24470
LITTLE ROCK AR
72221-4470
US

V. Phone/Fax

Practice location:
  • Phone: 501-565-0444
  • Fax:
Mailing address:
  • Phone: 501-781-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3321
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3763
License Number StateAR

VIII. Authorized Official

Name: BRYAN HILLER
Title or Position: OWNER
Credential:
Phone: 501-781-2777