Healthcare Provider Details

I. General information

NPI: 1306934583
Provider Name (Legal Business Name): RICHARD THOMAS PHELAN DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/14/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 RAHLING RD STE 101
LITTLE ROCK AR
72223-4777
US

IV. Provider business mailing address

1801 RAHLING RD STE 101
LITTLE ROCK AR
72223-4777
US

V. Phone/Fax

Practice location:
  • Phone: 501-224-6535
  • Fax: 501-224-8652
Mailing address:
  • Phone: 501-224-6535
  • Fax: 501-224-8652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3382
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: