Provider Demographics
NPI:1508889478
Name:G FRIEND DDS MS & M WILSON DDS MS PA
Entity Type:Organization
Organization Name:G FRIEND DDS MS & M WILSON DDS MS PA
Other - Org Name:NORTH LITTLE ROCK PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:501-771-2990
Mailing Address - Street 1:4605 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116
Mailing Address - Country:US
Mailing Address - Phone:501-771-2990
Mailing Address - Fax:501-753-0408
Practice Address - Street 1:4605 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116
Practice Address - Country:US
Practice Address - Phone:501-771-2990
Practice Address - Fax:501-758-0408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR28171223P0221X
AR27931223P0221X
AR27001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B771OtherBCBS