Provider Demographics
NPI:1033155411
Name:NORTHWEST ARKANSAS PEDIATRIC DENTAL CENTER
Entity Type:Organization
Organization Name:NORTHWEST ARKANSAS PEDIATRIC DENTAL CENTER
Other - Org Name:SMILE SHOPPE PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:RHODES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-631-6377
Mailing Address - Street 1:5518 WALSH LN
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8947
Mailing Address - Country:US
Mailing Address - Phone:479-631-6377
Mailing Address - Fax:479-273-5967
Practice Address - Street 1:5518 WALSH LN
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8947
Practice Address - Country:US
Practice Address - Phone:479-631-6377
Practice Address - Fax:479-273-5967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR29241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159561631Medicaid