Provider Demographics
NPI:1043671332
Name:PEA RIDGE FAMILY & COSMETIC DENTISTRY BY WISENER, COOPER, & FERGUS
Entity Type:Organization
Organization Name:PEA RIDGE FAMILY & COSMETIC DENTISTRY BY WISENER, COOPER, & FERGUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WELDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-7100
Mailing Address - Street 1:833 N CURTIS AVE
Mailing Address - Street 2:
Mailing Address - City:PEA RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72751-2930
Mailing Address - Country:US
Mailing Address - Phone:479-488-6288
Mailing Address - Fax:
Practice Address - Street 1:833 N CURTIS AVE
Practice Address - Street 2:
Practice Address - City:PEA RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72751-2930
Practice Address - Country:US
Practice Address - Phone:479-488-6288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISENER, COOPER, & FERGUS, DDS,PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3270122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty