Provider Demographics
NPI:1437834678
Name:GLENWOOD FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GLENWOOD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:SORRELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-356-3920
Mailing Address - Street 1:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:71943-0431
Mailing Address - Country:US
Mailing Address - Phone:870-356-3920
Mailing Address - Fax:
Practice Address - Street 1:119 ELM
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:AR
Practice Address - Zip Code:71943-9213
Practice Address - Country:US
Practice Address - Phone:870-356-3920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-15
Last Update Date:2023-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental