Healthcare Provider Details

I. General information

NPI: 1164892352
Provider Name (Legal Business Name): BOLD DENTAL POTTSVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7146 SR 247
POTTSVILLE AR
72858-8891
US

IV. Provider business mailing address

7146 SR 247
POTTSVILLE AR
72858-8891
US

V. Phone/Fax

Practice location:
  • Phone: 479-858-7382
  • Fax:
Mailing address:
  • Phone: 479-858-7382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateAR

VIII. Authorized Official

Name: WENDY PEDUTO
Title or Position: TRANSITION MANAGER
Credential:
Phone: 501-436-0518