Provider Demographics
NPI:1114479136
Name:ARKANSAS DENTAL PROFESSIONALS, MONGRAIN, P.A
Entity Type:Organization
Organization Name:ARKANSAS DENTAL PROFESSIONALS, MONGRAIN, P.A
Other - Org Name:MARKHAM FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:TEUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:5500 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3412
Mailing Address - Country:US
Mailing Address - Phone:501-664-6888
Mailing Address - Fax:
Practice Address - Street 1:5500 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3412
Practice Address - Country:US
Practice Address - Phone:501-664-6888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARKANSAS DENTAL PROFESSIONALS, MONGRAIN, P.A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty