Provider Demographics
NPI:1508962937
Name:WOOD DENTAL GROUP, P.A.
Entity Type:Organization
Organization Name:WOOD DENTAL GROUP, P.A.
Other - Org Name:WOOD & COOK DENTAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-735-3601
Mailing Address - Street 1:715 CALVIN AVERY DR
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301
Mailing Address - Country:US
Mailing Address - Phone:870-735-3601
Mailing Address - Fax:870-732-9535
Practice Address - Street 1:715 CALVIN AVERY
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-735-3601
Practice Address - Fax:870-732-9535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101993608Medicaid