Provider Demographics
NPI:1275622755
Name:PICKETT, MARK E (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:PICKETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CASH RD NW
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71701-3833
Mailing Address - Country:US
Mailing Address - Phone:870-836-5003
Mailing Address - Fax:870-836-3163
Practice Address - Street 1:135 CASH RD NW
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-3833
Practice Address - Country:US
Practice Address - Phone:870-836-5003
Practice Address - Fax:870-836-3163
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR25581223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58716OtherBCBS
AR884614OtherUNITED CONCORDIA