Provider Demographics
NPI:1093979254
Name:FERGUS, KELLY-GWYNNE MASON (DDS, MDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY-GWYNNE
Middle Name:MASON
Last Name:FERGUS
Suffix:
Gender:F
Credentials:DDS, MDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2812 HARRISBURG RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6081
Mailing Address - Country:US
Mailing Address - Phone:870-336-3366
Mailing Address - Fax:870-336-3360
Practice Address - Street 1:2812 HARRISBURG RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6081
Practice Address - Country:US
Practice Address - Phone:870-336-3366
Practice Address - Fax:870-336-3360
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR36591223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics