Provider Demographics
NPI:1558588764
Name:CRAWFORD-SEBASTIAN COMMUNITY DEVELOPMENT
Entity Type:Organization
Organization Name:CRAWFORD-SEBASTIAN COMMUNITY DEVELOPMENT
Other - Org Name:COMMUNITY DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-785-2303
Mailing Address - Street 1:PO BOX 4069
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72914-4069
Mailing Address - Country:US
Mailing Address - Phone:479-785-2303
Mailing Address - Fax:479-785-2341
Practice Address - Street 1:109 NO. 17TH
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901
Practice Address - Country:US
Practice Address - Phone:479-782-6021
Practice Address - Fax:479-709-0161
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRAWFORD-SEBASTIAN COMMUNITY DEVELOPMENT COUNCIL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-19
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1223D0001X
AR101872002302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101872002Medicaid