Healthcare Provider Details

I. General information

NPI: 1245829027
Provider Name (Legal Business Name): ORAL SURGERY OF CENTRAL ARKANSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 FAIRWAY AVE STE D
NORTH LITTLE ROCK AR
72116-8069
US

IV. Provider business mailing address

4701 FAIRWAY AVE STE D
NORTH LITTLE ROCK AR
72116-8069
US

V. Phone/Fax

Practice location:
  • Phone: 501-791-7600
  • Fax: 501-791-2824
Mailing address:
  • Phone: 501-327-5255
  • Fax: 501-791-2824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER PATTERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 13-275-2555