Healthcare Provider Details

I. General information

NPI: 1932448032
Provider Name (Legal Business Name): D MICHAEL DERUYTER D D S INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3447 HIGHWAY 270 E
MOUNT IDA AR
71957-8092
US

IV. Provider business mailing address

3447 HIGHWAY 270 E
MOUNT IDA AR
71957-8092
US

V. Phone/Fax

Practice location:
  • Phone: 870-867-4110
  • Fax: 870-867-2207
Mailing address:
  • Phone: 870-867-4110
  • Fax: 870-867-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID MICHAEL DERUYTER
Title or Position: PRESIDENT
Credential: D D S
Phone: 870-867-4110