Healthcare Provider Details

I. General information

NPI: 1811911100
Provider Name (Legal Business Name): ANDREW THOMAS BAIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 N MOCK ST
PRAIRIE GROVE AR
72753
US

IV. Provider business mailing address

PO BOX 913
PRAIRIE GROVE AR
72753-0913
US

V. Phone/Fax

Practice location:
  • Phone: 479-846-3114
  • Fax:
Mailing address:
  • Phone: 479-846-3114
  • Fax: 479-846-4144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2726
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: