Provider Demographics
NPI:1073735221
Name:MASON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MASON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CONLEY
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-984-5177
Mailing Address - Street 1:4585 N HIGHWAY 7 STE 13
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71909-8202
Mailing Address - Country:US
Mailing Address - Phone:501-984-5177
Mailing Address - Fax:501-984-6350
Practice Address - Street 1:4585 N HIGHWAY 7 STE 13
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71909
Practice Address - Country:US
Practice Address - Phone:501-984-5177
Practice Address - Fax:501-984-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152459631Medicaid