Provider Demographics
NPI:1487021465
Name:KIDZ CHOICE WEST MEMPHIS PLLC
Entity Type:Organization
Organization Name:KIDZ CHOICE WEST MEMPHIS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-225-1577
Mailing Address - Street 1:12018 CHENAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2759
Mailing Address - Country:US
Mailing Address - Phone:501-225-1577
Mailing Address - Fax:501-219-4780
Practice Address - Street 1:316 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4225
Practice Address - Country:US
Practice Address - Phone:870-400-8127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEWART DENTAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-26
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1487021465Medicaid