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General NPI Number Information
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NPI Number | 1558538181
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Entity Type | Organization
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Legal Business Name | ARKANSAS DENTAL CLINIC
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Dates
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Enumeration Date | 05/13/2008
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 3409 GATEWAY COVE
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City | JONESBORO
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State | AR
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Zip | 72404
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Country | US
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Telephone | 870-336-0543
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Fax |
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Provider Business Mailing Address
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Address Line | 3409 GATEWAY COVE
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City | JONESBORO
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State | AR
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Zip | 72404
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Country | US
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Telephone | 870-336-0543
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DIANE SECREASE
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Credential | RDA CDA
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Telephone | 870-932-0330
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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 | 2621
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License Number State | AR
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