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General NPI Number Information
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NPI Number | 1659819738
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Entity Type | Organization
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Legal Business Name | HERITAGE LEGACY DENTAL CARE, INC
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Dates
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Enumeration Date | 02/08/2017
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Last Update Date | 02/08/2017
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Provider Practice Location Address
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Address Line | 7 EDENWOOD LN
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City | N LITTLE ROCK
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State | AR
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Zip | 72116-5105
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Country | US
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Telephone | 501-771-4500
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Fax | 901-763-3573
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Provider Business Mailing Address
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Address Line | 7 EDENWOOD LN
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City | N LITTLE ROCK
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State | AR
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Zip | 72116-5105
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Country | US
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Telephone | 501-771-4500
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Fax | 901-763-3573
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WADE ROBERTSON
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Credential | DDS
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Telephone | 501-771-4500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3220
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License Number State | AR
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