Provider Demographics
NPI:1003258245
Name:ARKANSAS PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:ARKANSAS PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-350-6416
Mailing Address - Street 1:5905 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1608
Mailing Address - Country:US
Mailing Address - Phone:501-350-6416
Mailing Address - Fax:
Practice Address - Street 1:5905 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1608
Practice Address - Country:US
Practice Address - Phone:501-350-6416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR37331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179325608Medicaid