Provider Demographics
NPI:1477219228
Name:GOTTSPONER FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:GOTTSPONER FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTSPONER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-215-1474
Mailing Address - Street 1:914 E DRILLING ST
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110-2218
Mailing Address - Country:US
Mailing Address - Phone:501-354-1305
Mailing Address - Fax:
Practice Address - Street 1:914 E DRILLING ST
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-2218
Practice Address - Country:US
Practice Address - Phone:501-354-1305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR269285608Medicaid