Provider Demographics
NPI:1215229786
Name:MAXILLOFACIAL DIAGNOSTICS, PLLC
Entity Type:Organization
Organization Name:MAXILLOFACIAL DIAGNOSTICS, PLLC
Other - Org Name:MAXILLOFACIAL DIAGNOSTICS, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROSTHODONTISTS
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:COCO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MDS, PA
Authorized Official - Phone:501-319-7520
Mailing Address - Street 1:2300 ANDOVER CT
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-3987
Mailing Address - Country:US
Mailing Address - Phone:501-319-7520
Mailing Address - Fax:501-319-7521
Practice Address - Street 1:2300 ANDOVER CT
Practice Address - Street 2:SUITE 400
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-3987
Practice Address - Country:US
Practice Address - Phone:501-319-7520
Practice Address - Fax:501-319-7521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR35331223P0700X
AR35431223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty