Healthcare Provider Details

I. General information

NPI: 1609025451
Provider Name (Legal Business Name): MARY ANN WEATHERFORD DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JULIA AVE E
WYNNE AR
72396-3504
US

IV. Provider business mailing address

PO BOX 554 620 JULIA
WYNNE AR
72396-0554
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-2600
  • Fax: 870-238-5522
Mailing address:
  • Phone: 870-238-2600
  • Fax: 870-238-5522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3649
License Number StateAR

VIII. Authorized Official

Name: DR. MARY ANN WEATHERFORD
Title or Position: DENTIST
Credential: DDS, PA
Phone: 870-697-2606