Provider Demographics
NPI:1154863637
Name:WEST MEMPHIS PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:WEST MEMPHIS PEDIATRIC 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:MICHAEL
Authorized Official - Last Name:BURROWS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-739-2992
Mailing Address - Street 1:316 W TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4225
Mailing Address - Country:US
Mailing Address - Phone:870-735-5439
Mailing Address - Fax:870-739-8597
Practice Address - Street 1:303 BANCARIO STE 11-12
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-2825
Practice Address - Country:US
Practice Address - Phone:870-739-2992
Practice Address - Fax:870-739-8597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3647261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental