Provider Demographics
NPI:1144242736
Name:HOT SPRING VILLAGE DENTISTRY
Entity Type:Organization
Organization Name:HOT SPRING VILLAGE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FUSILIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-922-6700
Mailing Address - Street 1:101 DENTISTA DR
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71909-3503
Mailing Address - Country:US
Mailing Address - Phone:501-922-6700
Mailing Address - Fax:501-922-6357
Practice Address - Street 1:101 DENTISTA DR
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71909-3503
Practice Address - Country:US
Practice Address - Phone:501-922-6700
Practice Address - Fax:501-922-6357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR29471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========OtherTAX ID NUMBER