Provider Demographics
NPI:1225242464
Name:HIGHLAND FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:HIGHLAND FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-856-4050
Mailing Address - Street 1:1474 HIGHWAY 62 412
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72542-9170
Mailing Address - Country:US
Mailing Address - Phone:870-856-4050
Mailing Address - Fax:870-856-4088
Practice Address - Street 1:1474 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9170
Practice Address - Country:US
Practice Address - Phone:870-856-4050
Practice Address - Fax:870-856-4088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146516631Medicaid