Provider Demographics
NPI:1376904953
Name:SOUTHERN DENTAL OF JONESBORO, PLLC
Entity Type:Organization
Organization Name:SOUTHERN DENTAL OF JONESBORO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:REYNOLDS
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-243-4406
Mailing Address - Street 1:2500 BROWNS LN STE A
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6107
Mailing Address - Country:US
Mailing Address - Phone:870-243-4406
Mailing Address - Fax:
Practice Address - Street 1:2500 BROWNS LN STE A
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6107
Practice Address - Country:US
Practice Address - Phone:870-243-4406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR39301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty