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General NPI Number Information
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NPI Number | 1396803722
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Entity Type | Organization
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Legal Business Name | ARKANSAS DENTAL PROFESSIONALS, MONGRAIN, P.A.
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 10/08/2025
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Provider Practice Location Address
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Address Line | 635 FAYETTEVILLE RD
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City | VAN BUREN
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State | AR
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Zip | 72956-3418
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Country | US
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Telephone | 479-474-9696
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Fax |
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Provider Business Mailing Address
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Address Line | 635 FAYETTEVILLE RD
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City | VAN BUREN
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State | AR
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Zip | 72956-3418
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Country | US
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Telephone | 479-474-9696
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | HILLARY THULL
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Credential |
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Telephone | 217-540-8946
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3370
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License Number State | AR
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