Provider Demographics
NPI:1346643699
Name:AR PERIODONTAL & IMPLANT ASSOC
Entity Type:Organization
Organization Name:AR PERIODONTAL & IMPLANT ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:RABEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-521-6400
Mailing Address - Street 1:2001 N GREEN ACRES RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2619
Mailing Address - Country:US
Mailing Address - Phone:479-521-6400
Mailing Address - Fax:479-521-0164
Practice Address - Street 1:1405 MCCOY DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2417
Practice Address - Country:US
Practice Address - Phone:479-521-6400
Practice Address - Fax:479-521-0164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AR PERIODONTAL & IMPLANT ASSOC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-01
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty