Healthcare Provider Details

I. General information

NPI: 1396189270
Provider Name (Legal Business Name): PINNACLE PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 BRECKENRIDGE DR #110
LITTLE ROCK AR
72205-1558
US

IV. Provider business mailing address

1225 BRECKENRIDGE DR #110
LITTLE ROCK AR
72205-1558
US

V. Phone/Fax

Practice location:
  • Phone: 501-225-4644
  • Fax: 501-225-4102
Mailing address:
  • Phone: 501-225-4644
  • Fax: 501-225-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3613
License Number StateAR

VIII. Authorized Official

Name: DR. MATTHEW D CARLISLE
Title or Position: OWNER/PERIODONTIST
Credential: D.D.S., M.S.
Phone: 501-225-4644