Provider Demographics
NPI:1477148542
Name:LAFAYETTE COUNTY DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:LAFAYETTE COUNTY DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GILES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-276-6329
Mailing Address - Street 1:506 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:STAMPS
Mailing Address - State:AR
Mailing Address - Zip Code:71860-2540
Mailing Address - Country:US
Mailing Address - Phone:202-276-6329
Mailing Address - Fax:
Practice Address - Street 1:506 THOMAS ST
Practice Address - Street 2:
Practice Address - City:STAMPS
Practice Address - State:AR
Practice Address - Zip Code:71860-2540
Practice Address - Country:US
Practice Address - Phone:202-276-6329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental