Provider Demographics
NPI:1417159427
Name:ARKANSAS DENTAL CENTER
Entity Type:Organization
Organization Name:ARKANSAS DENTAL CENTER
Other - Org Name:ARKANSAS DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-847-9191
Mailing Address - Street 1:612 W COMMERCE ST
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-7514
Mailing Address - Country:US
Mailing Address - Phone:501-847-9191
Mailing Address - Fax:501-847-8337
Practice Address - Street 1:612 W COMMERCE ST
Practice Address - Street 2:SUITE ONE
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-7514
Practice Address - Country:US
Practice Address - Phone:501-847-9191
Practice Address - Fax:501-847-8337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3065122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T579OtherABCBS PROVIDER NUMBER
AR1174534804OtherNATIONAL PROVIDER IDENTIF