Healthcare Provider Details

I. General information

NPI: 1508889478
Provider Name (Legal Business Name): G FRIEND DDS MS & M WILSON DDS MS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 FAIRWAY AVE
NORTH LITTLE ROCK AR
72116
US

IV. Provider business mailing address

4605 FAIRWAY AVE
NORTH LITTLE ROCK AR
72116
US

V. Phone/Fax

Practice location:
  • Phone: 501-771-2990
  • Fax: 501-758-0408
Mailing address:
  • Phone: 501-771-2990
  • Fax: 501-753-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2817
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2700
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2793
License Number StateAR

VIII. Authorized Official

Name: DR. MARK E WILSON
Title or Position: CO OWNER
Credential: DDS MS
Phone: 501-771-2990