=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033155411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST ARKANSAS PEDIATRIC DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 01/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5518 WALSH LN
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-8947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-631-6377
-----------------------------------------------------
Fax | 479-273-5967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5518 WALSH LN
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-8947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-631-6377
-----------------------------------------------------
Fax | 479-273-5967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY D RHODES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-631-6377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 2924
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------