Healthcare Provider Details

I. General information

NPI: 1912500364
Provider Name (Legal Business Name): RONNIE L FAULKNER, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 HIGHWAY 270 E
MOUNT IDA AR
71957-9409
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RONNIE LEE FAULKNER
Title or Position: PRESIDE
Credential: DDS
Phone: 501-276-3432