Healthcare Provider Details

I. General information

NPI: 1659963890
Provider Name (Legal Business Name): NICHOLAS M DORE PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 GABRIEL WAY
SULPHUR ROCK AR
72579-9012
US

IV. Provider business mailing address

15 GABRIEL WAY
SULPHUR ROCK AR
72579-9012
US

V. Phone/Fax

Practice location:
  • Phone: 870-656-8646
  • Fax:
Mailing address:
  • Phone: 870-656-8646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberL.AC.023
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: