=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316087794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL L MCCRACKEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 891 N MAIN AVE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-8850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-444-0202
-----------------------------------------------------
Fax | 479-251-9578
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1235 E RODGERS DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-444-0354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2954
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------