Provider Demographics
NPI:1508054214
Name:S TODD PHELAN, DDS, PA
Entity Type:Organization
Organization Name:S TODD PHELAN, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-636-3400
Mailing Address - Street 1:2102 W PLEASANT GROVE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758
Mailing Address - Country:US
Mailing Address - Phone:479-636-3400
Mailing Address - Fax:479-636-3407
Practice Address - Street 1:2102 W PLEASANT GROVE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758
Practice Address - Country:US
Practice Address - Phone:479-636-3400
Practice Address - Fax:479-636-3407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167741631Medicaid