MEDICARE: LAFAYETTE COUNTY DENTAL CLINIC, INC.

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1477148542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAFAYETTE COUNTY DENTAL CLINIC, INC.

Provider Business Mailing Address
First Line	:	506 THOMAS ST
Second Line	:
City	:	STAMPS
State	:	AR
Zip	:	71860-2540
Country	:	US
Telephone Number	:	202-276-6329
Fax Number	:

Provider Business Practice Location Address
First Line	:	506 THOMAS ST
Second Line	:
City	:	STAMPS
State	:	AR
Zip	:	71860-2540
Country	:	US
Telephone Number	:	202-276-6329
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GILES WILLIS JR.
Credential	:	DDS
Telephone Number	:	202-276-6329

Provider Enumeration Date	:	03/01/2021
Last Update Date	:	03/01/2021

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