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General NPI Number Information
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NPI Number | 1881018786
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Entity Type | Organization
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Legal Business Name | MY VILLAGE SMILES, PLLC
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Dates
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Enumeration Date | 02/12/2014
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Last Update Date | 02/12/2014
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Provider Practice Location Address
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Address Line | 1104 POPLAR PL
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City | ROGERS
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State | AR
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Zip | 72756-4249
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Country | US
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Telephone | 479-621-9500
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Fax | 479-202-5361
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Provider Business Mailing Address
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Address Line | 1104 POPLAR PL
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City | ROGERS
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State | AR
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Zip | 72756-4249
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Country | US
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Telephone | 479-621-9500
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Fax | 479-202-5361
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Authorized Official
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Title or Position | OWNER
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Name | WILLIAM T MAHON
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Credential | D.D.S., M.S., M.S
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Telephone | 479-621-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2401
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 2401
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License Number State | AR
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