Healthcare Provider Details

I. General information

NPI: 1124491733
Provider Name (Legal Business Name): ORAL SURGERY OF CENTRAL ARKANSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 MCCAIN BLVD STE 202
NORTH LITTLE ROCK AR
72116-7612
US

IV. Provider business mailing address

2504 MCCAIN BLVD STE 202
NORTH LITTLE ROCK AR
72116-7612
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number2606
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number3775
License Number StateAR

VIII. Authorized Official

Name: DR. JOHN M JOHNSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 501-327-5255