Provider Demographics
NPI:1518085620
Name:WARREN DENTAL, PLLC
Entity Type:Organization
Organization Name:WARREN DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:W
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-745-4656
Mailing Address - Street 1:390 FACTORY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031-6742
Mailing Address - Country:US
Mailing Address - Phone:501-745-4656
Mailing Address - Fax:501-745-6317
Practice Address - Street 1:390 FACTORY RD
Practice Address - Street 2:SUITE A
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-6742
Practice Address - Country:US
Practice Address - Phone:501-745-4656
Practice Address - Fax:501-745-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR21401223G0001X
AR35281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187471631Medicaid