MEDICARE: ARKANSAS DENTAL PROFESSIONALS MONGRAIN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225179088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARKANSAS DENTAL PROFESSIONALS MONGRAIN PA

Provider Business Mailing Address
First Line	:	2909 S 74TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5156
Country	:	US
Telephone Number	:	479-452-7454
Fax Number	:	479-484-5908

Provider Business Practice Location Address
First Line	:	2909 S 74TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5156
Country	:	US
Telephone Number	:	479-452-7454
Fax Number	:	479-484-5908

Authorized Official
Title or Position	:	DIRECTOR OF DENTAL INSURANCE
Name	:	MRS. MARIE KUHL
Credential	:
Telephone Number	:	217-540-5146

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	07/20/2020

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Directions to “ARKANSAS DENTAL PROFESSIONALS MONGRAIN PA ” Practice Location

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