Provider Demographics
NPI:1366644635
Name:WILLMUTH DENTISTRY
Entity Type:Organization
Organization Name:WILLMUTH DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILLMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-886-6761
Mailing Address - Street 1:413 SW 3RD ST
Mailing Address - Street 2:PO BOX 713
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-2310
Mailing Address - Country:US
Mailing Address - Phone:870-886-6761
Mailing Address - Fax:870-886-6762
Practice Address - Street 1:413 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-2310
Practice Address - Country:US
Practice Address - Phone:870-886-6761
Practice Address - Fax:870-886-6762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58790OtherPROVIDER ID