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General NPI Number Information
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NPI Number | 1396189270
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Entity Type | Organization
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Legal Business Name | PINNACLE PERIODONTICS
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Dates
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Enumeration Date | 04/23/2013
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Last Update Date | 04/23/2013
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Provider Practice Location Address
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Address Line | 1225 BRECKENRIDGE DR #110
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City | LITTLE ROCK
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State | AR
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Zip | 72205-1558
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Country | US
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Telephone | 501-225-4644
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Fax | 501-225-4102
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Provider Business Mailing Address
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Address Line | 1225 BRECKENRIDGE DR #110
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City | LITTLE ROCK
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State | AR
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Zip | 72205-1558
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Country | US
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Telephone | 501-225-4644
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Fax | 501-225-4102
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Authorized Official
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Title or Position | OWNER/PERIODONTIST
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Name | DR. MATTHEW D CARLISLE
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Credential | D.D.S., M.S.
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Telephone | 501-225-4644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 3613
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License Number State | AR
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