=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528253416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST ARKANSAS ENDODONTIC SPECIALISTS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2007
-----------------------------------------------------
Last Update Date | 09/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1831 N GREEN ACRES RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-521-2814
-----------------------------------------------------
Fax | 479-521-5842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1831 N GREEN ACRES RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-521-2814
-----------------------------------------------------
Fax | 479-521-5842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAMES MARTIN TINNIN
-----------------------------------------------------
Credential | D.D.S., M.S.D.
-----------------------------------------------------
Telephone | 479-521-2814
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 1998
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------