Provider Demographics
NPI:1497251201
Name:SOH OF ARKANSAS WILLIAM WELLFORD PC
Entity Type:Organization
Organization Name:SOH OF ARKANSAS WILLIAM WELLFORD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL SUPPORT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-753-8154
Mailing Address - Street 1:2868 W MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7625
Mailing Address - Country:US
Mailing Address - Phone:870-672-2407
Mailing Address - Fax:
Practice Address - Street 1:2868 W MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-7625
Practice Address - Country:US
Practice Address - Phone:870-672-2407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL CARE OF FAYETTEVILLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty