Provider Demographics
NPI:1558538181
Name:ARKANSAS DENTAL CLINIC
Entity Type:Organization
Organization Name:ARKANSAS DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SECREASE
Authorized Official - Suffix:
Authorized Official - Credentials:RDA CDA
Authorized Official - Phone:870-932-0330
Mailing Address - Street 1:3409 GATEWAY COVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404
Mailing Address - Country:US
Mailing Address - Phone:870-336-0543
Mailing Address - Fax:
Practice Address - Street 1:3409 GATEWAY COVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404
Practice Address - Country:US
Practice Address - Phone:870-336-0543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty