Healthcare Provider Details

I. General information

NPI: 1568525731
Provider Name (Legal Business Name): RONNIE LEE FAULKNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 HWY 270 EAST
MOUNT IDA AR
71957-0901
US

IV. Provider business mailing address

PO BOX 901
MOUNT IDA AR
71957-0901
US

V. Phone/Fax

Practice location:
  • Phone: 870-867-3432
  • Fax: 870-867-3783
Mailing address:
  • Phone: 870-867-3432
  • Fax: 870-867-3783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2688
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: