Healthcare Provider Details

I. General information

NPI: 1033155411
Provider Name (Legal Business Name): NORTHWEST ARKANSAS PEDIATRIC DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5518 WALSH LN
ROGERS AR
72758-8947
US

IV. Provider business mailing address

5518 WALSH LN
ROGERS AR
72758-8947
US

V. Phone/Fax

Practice location:
  • Phone: 479-631-6377
  • Fax: 479-273-5967
Mailing address:
  • Phone: 479-631-6377
  • Fax: 479-273-5967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2924
License Number StateAR

VIII. Authorized Official

Name: DR. JEFFREY D RHODES
Title or Position: PRESIDENT
Credential:
Phone: 479-631-6377