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General NPI Number Information
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NPI Number | 1972930295
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Entity Type | Organization
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Legal Business Name | MAIN STREET DENTAL PLLC
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Dates
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Enumeration Date | 10/01/2013
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Last Update Date | 10/01/2013
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Provider Practice Location Address
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Address Line | 312 S MAIN ST
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City | BENTONVILLE
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State | AR
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Zip | 72712-5903
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Country | US
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Telephone | 479-254-6899
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Fax | 479-254-6749
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Provider Business Mailing Address
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Address Line | 312 S MAIN ST
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City | BENTONVILLE
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State | AR
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Zip | 72712-5903
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Country | US
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Telephone | 479-254-6899
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Fax | 479-254-6749
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Authorized Official
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Title or Position | MEMBER/MANAGER
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Name | BENJAMIN D. HALL
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Credential | DDS
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Telephone | 479-254-6899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 3599
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License Number State | AR
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