Provider Demographics
NPI:1417109570
Name:BRIEN S DOUGLAS DDS PA
Entity Type:Organization
Organization Name:BRIEN S DOUGLAS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-623-9882
Mailing Address - Street 1:2212 MALVERN AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-8038
Mailing Address - Country:US
Mailing Address - Phone:501-623-9882
Mailing Address - Fax:501-623-8424
Practice Address - Street 1:2212 MALVERN AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-8038
Practice Address - Country:US
Practice Address - Phone:501-623-9882
Practice Address - Fax:501-623-8424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3372122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145104608Medicaid