=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912250655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL DENTAL - CONWAY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2012
-----------------------------------------------------
Last Update Date | 10/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2415 PRINCE STREET
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72034-3746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-327-6453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2415 PRINCE ST
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72034-3746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-327-6453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TODD C STEWART
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 501-225-1577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------