Provider Demographics
NPI:1043609522
Name:BRACES OF THE OZARKS, LLC
Entity Type:Organization
Organization Name:BRACES OF THE OZARKS, LLC
Other - Org Name:TATUM ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-781-2777
Mailing Address - Street 1:5100 TALLEY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-8032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 N MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2914
Practice Address - Country:US
Practice Address - Phone:501-781-2777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty