Provider Demographics
NPI:1508114067
Name:AR DENTAL & TMJ - LITTLE ROCK, LLC
Entity Type:Organization
Organization Name:AR DENTAL & TMJ - LITTLE ROCK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUPAN
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:12018 CHENAL PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2759
Practice Address - Country:US
Practice Address - Phone:501-225-1577
Practice Address - Fax:501-219-4780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR192473680Medicaid