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General NPI Number Information
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NPI Number | 1508454612
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Entity Type | Organization
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Legal Business Name | PRAIRIE GROVE DENTAL CENTER PLLC
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Dates
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Enumeration Date | 01/05/2021
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Last Update Date | 01/05/2021
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Provider Practice Location Address
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Address Line | 1121 E HERITAGE PKWY
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City | PRAIRIE GROVE
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State | AR
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Zip | 72753-6013
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Country | US
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Telephone | 479-244-2052
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Fax | 479-846-1940
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Provider Business Mailing Address
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Address Line | 1121 E HERITAGE PKWY
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City | PRAIRIE GROVE
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State | AR
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Zip | 72753-6013
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Country | US
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Telephone | 479-244-2052
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Fax | 479-846-1940
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Authorized Official
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Title or Position | DENTIST-OWNER
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Name | DR. ALAN DOUGLAS CLARK
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Credential | DDS
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Telephone | 479-244-2052
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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 |
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License Number State |
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