Healthcare Provider Details

I. General information

NPI: 1043139496
Provider Name (Legal Business Name): ALEX PISTORIUS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 SLACK STREET
PEA RIDGE AR
72751-5042
US

IV. Provider business mailing address

459 SLACK STREET
PEA RIDGE AR
72751-5042
US

V. Phone/Fax

Practice location:
  • Phone: 479-488-3020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4942
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: