Provider Demographics
NPI:1497765903
Name:FALLIS, DALE THOMAS
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:THOMAS
Last Name:FALLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SUSIE
Other - Middle Name:R
Other - Last Name:AKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10500 W. MARKHAM ST
Mailing Address - Street 2:STE 104
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-223-2773
Mailing Address - Fax:501-223-2358
Practice Address - Street 1:10500 W MARKHAM ST
Practice Address - Street 2:STE 104
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-2140
Practice Address - Country:US
Practice Address - Phone:501-223-2773
Practice Address - Fax:501-223-2358
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice