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General NPI Number Information
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NPI Number | 1528853934
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Entity Type | Organization
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Legal Business Name | LEGACY DENTAL
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Dates
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Enumeration Date | 04/14/2025
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Last Update Date | 04/14/2025
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Provider Practice Location Address
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Address Line | 901 S PROMENADE BLVD
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City | ROGERS
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State | AR
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Zip | 72758-1801
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Country | US
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Telephone | 501-412-2717
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Fax |
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Provider Business Mailing Address
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Address Line | 6791 GARDEN TRAIL AVE
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City | SPRINGDALE
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State | AR
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Zip | 72762-7048
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Country | US
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Telephone | 501-412-2717
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. JACK REID FAWCETT
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Credential | DDS
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Telephone | 501-412-2717
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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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