Healthcare Provider Details

I. General information

NPI: 1003903287
Provider Name (Legal Business Name): RICHARD GREGORY ELIMON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504MECAIN 202
NORTH LITTLE ROCK AR
72116
US

IV. Provider business mailing address

700 LAKETREELANE
SHERWOOD AR
72120
US

V. Phone/Fax

Practice location:
  • Phone: 501-771-7600
  • Fax:
Mailing address:
  • Phone: 501-833-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2606
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: