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General NPI Number Information
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NPI Number | 1659727469
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Entity Type | Organization
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Legal Business Name | GREEN DENTAL LAB, INC.
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Dates
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Enumeration Date | 05/11/2016
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Last Update Date | 05/11/2016
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Provider Practice Location Address
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Address Line | 1099 WILBURN RD
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City | HEBER SPRINGS
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State | AR
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Zip | 72543-8905
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Country | US
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Telephone | 501-362-3132
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Fax | 501-362-4717
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Provider Business Mailing Address
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Address Line | 1099 WILBURN RD
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City | HEBER SPRINGS
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State | AR
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Zip | 72543-8905
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Country | US
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Telephone | 501-362-3132
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Fax | 501-362-4717
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Authorized Official
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Title or Position | LAB PRESIDENT
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Name | MRS. KIMBERLY THOMAS
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Credential |
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Telephone | 501-362-3132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 292200000X
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Taxonomy Name | Dental Laboratory
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License Number | 123277-00
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License Number State | AR
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