Healthcare Provider Details

I. General information

NPI: 1508114067
Provider Name (Legal Business Name): AR DENTAL & TMJ - LITTLE ROCK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12018 CHENAL PKWY
LITTLE ROCK AR
72211-2759
US

IV. Provider business mailing address

12018 CHENAL PKWY
LITTLE ROCK AR
72211-2759
US

V. Phone/Fax

Practice location:
  • Phone: 501-225-1577
  • Fax: 501-219-4780
Mailing address:
  • Phone: 501-225-1577
  • Fax: 501-219-4780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3396
License Number StateAR

VIII. Authorized Official

Name: MS. ERIN CUPAN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 501-225-1577