Provider Demographics
NPI:1225179088
Name:ARKANSAS DENTAL PROFESSIONALS MONGRAIN PA
Entity Type:Organization
Organization Name:ARKANSAS DENTAL PROFESSIONALS MONGRAIN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DENTAL INSURANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5146
Mailing Address - Street 1:2909 S 74TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5156
Mailing Address - Country:US
Mailing Address - Phone:479-452-7454
Mailing Address - Fax:479-484-5908
Practice Address - Street 1:2909 S 74TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5156
Practice Address - Country:US
Practice Address - Phone:479-452-7454
Practice Address - Fax:479-484-5908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
AR21621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162147631Medicaid
OK200078290AMedicaid
AR162147631Medicaid