Healthcare Provider Details

I. General information

NPI: 1366008781
Provider Name (Legal Business Name): ARKANSAS MAXILLOFACIAL SURGERY CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 HIGHLAND DR
LITTLE ROCK AR
72223-2002
US

IV. Provider business mailing address

5400 HIGHLAND DR
LITTLE ROCK AR
72223-2002
US

V. Phone/Fax

Practice location:
  • Phone: 501-225-8929
  • Fax:
Mailing address:
  • Phone: 501-225-8929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MIKE COLE
Title or Position: VP INSURANCE PLAN MANAGEMENT
Credential:
Phone: 727-424-2990