=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720316359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE RIVER DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2009
-----------------------------------------------------
Last Update Date | 11/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 259 EAGLE MOUNTAIN BLVD
-----------------------------------------------------
City | BATESVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72501-4232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-698-0900
-----------------------------------------------------
Fax | 870-698-0332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 259 EAGLE MOUNTAIN BLVD
-----------------------------------------------------
City | BATESVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72501-4232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-698-0900
-----------------------------------------------------
Fax | 870-698-0332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. MARK W CHUNN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 870-698-0900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3078
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------