Provider Demographics
NPI:1063820215
Name:BOLD DENTAL PARTNERS, PLLC FT. SMITH
Entity Type:Organization
Organization Name:BOLD DENTAL PARTNERS, PLLC FT. SMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-717-1047
Mailing Address - Street 1:8309 PHOENIX AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-6141
Mailing Address - Country:US
Mailing Address - Phone:479-484-7645
Mailing Address - Fax:479-484-1551
Practice Address - Street 1:8309 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6141
Practice Address - Country:US
Practice Address - Phone:479-484-7645
Practice Address - Fax:479-484-1551
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOLD DENTAL PARTNERS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR32421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty