Provider Demographics
NPI:1194226506
Name:GKLM, PLLC
Entity Type:Organization
Organization Name:GKLM, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-442-5092
Mailing Address - Street 1:1874 N HUNTERS RDG STE 1
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-2896
Mailing Address - Country:US
Mailing Address - Phone:479-442-5092
Mailing Address - Fax:479-587-0932
Practice Address - Street 1:1874 N HUNTERS RDG STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-2896
Practice Address - Country:US
Practice Address - Phone:479-442-5092
Practice Address - Fax:479-587-0932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR24391223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty