Provider Demographics
NPI:1407988116
Name:UT PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:UT PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-733-3854
Mailing Address - Street 1:200 W TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4223
Mailing Address - Country:US
Mailing Address - Phone:870-733-3854
Mailing Address - Fax:870-733-3851
Practice Address - Street 1:200 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4223
Practice Address - Country:US
Practice Address - Phone:870-733-3854
Practice Address - Fax:870-733-3851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150226608Medicaid
AR107199608Medicaid
AR111494608Medicaid