Healthcare Provider Details

I. General information

NPI: 1073954574
Provider Name (Legal Business Name): EFIRD & TEALE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 SOUTH MAIN
MALVERN AR
72104-4507
US

IV. Provider business mailing address

927 S MAIN ST
MALVERN AR
72104-5220
US

V. Phone/Fax

Practice location:
  • Phone: 501-337-9559
  • Fax: 501-337-7447
Mailing address:
  • Phone: 501-337-9559
  • Fax: 501-337-7447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2077
License Number StateAR

VIII. Authorized Official

Name: ROBIN HERRON
Title or Position: OFIICE MANAGER
Credential:
Phone: 501-337-9559