Healthcare Provider Details

I. General information

NPI: 1265517213
Provider Name (Legal Business Name): CHARLES ANDY VONDRAN JR. D.D.S. , M.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 N RODNEY PARHAM RD SUITE 310
LITTLE ROCK AR
72212-2453
US

IV. Provider business mailing address

4220 N RODNEY PARHAM RD SUITE 310
LITTLE ROCK AR
72212-2453
US

V. Phone/Fax

Practice location:
  • Phone: 501-224-3421
  • Fax:
Mailing address:
  • Phone: 501-224-3421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3350
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: