Provider Demographics
NPI:1558531889
Name:ARKANSAS TMJ CENTER LLC
Entity Type:Organization
Organization Name:ARKANSAS TMJ CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:W
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-660-7881
Mailing Address - Street 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 702
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-660-7899
Mailing Address - Fax:
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 702
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-660-7881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2976122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty