Healthcare Provider Details

I. General information

NPI: 1124563895
Provider Name (Legal Business Name): AXPM-MOUNTAIN HOME DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HOSPITAL DR
MOUNTAIN HOME AR
72653-2913
US

IV. Provider business mailing address

PO BOX 3450
LITTLE ROCK AR
72203-3450
US

V. Phone/Fax

Practice location:
  • Phone: 870-425-9757
  • Fax:
Mailing address:
  • Phone: 501-781-2777
  • Fax: 501-781-2778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK DAKE
Title or Position: OWNER
Credential:
Phone: 501-781-2777