MEDICARE: ARKANSAS DENTAL PROFESSIONALS, MONGRAIN, P.A.

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

General Provider Information

NPI Number	:	1922667898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARKANSAS DENTAL PROFESSIONALS, MONGRAIN, P.A.

Provider Business Mailing Address
First Line	:	9004 JENNY LIND RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8630
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9004 JENNY LIND RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8630
Country	:	US
Telephone Number	:	479-262-9101
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	TABATHA LEMKE
Credential	:
Telephone Number	:	217-540-6078

Provider Enumeration Date	:	06/13/2019
Last Update Date	:	06/13/2019

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