Provider Demographics
NPI:1508454612
Name:PRAIRIE GROVE DENTAL CENTER PLLC
Entity Type:Organization
Organization Name:PRAIRIE GROVE DENTAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-244-2052
Mailing Address - Street 1:1121 E HERITAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72753-6013
Mailing Address - Country:US
Mailing Address - Phone:479-244-2052
Mailing Address - Fax:479-846-1940
Practice Address - Street 1:1121 E HERITAGE PKWY
Practice Address - Street 2:
Practice Address - City:PRAIRIE GROVE
Practice Address - State:AR
Practice Address - Zip Code:72753-6013
Practice Address - Country:US
Practice Address - Phone:479-244-2052
Practice Address - Fax:479-846-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty