Healthcare Provider Details

I. General information

NPI: 1881852499
Provider Name (Legal Business Name): MARY ANN WEATHERFORD DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 08/22/2008
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

620 JULIA AVE E
WYNNE AR
72396-3504
US

V. Phone/Fax

Practice location:
  • Phone: 870-208-3115
  • Fax:
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:
Title or Position:
Credential:
Phone: