Healthcare Provider Details

I. General information

NPI: 1194866418
Provider Name (Legal Business Name): FT MCDONALD DDS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 S OLIVE ST
PINE BLUFF AR
71603-6745
US

IV. Provider business mailing address

3900 S OLIVE ST
PINE BLUFF AR
71603-6745
US

V. Phone/Fax

Practice location:
  • Phone: 870-536-6430
  • Fax:
Mailing address:
  • Phone: 879-036-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1983
License Number StateAR

VIII. Authorized Official

Name: FRED MCDONALD
Title or Position: PRESIDENT
Credential:
Phone: 870-536-6430