Provider Demographics
NPI:1578079307
Name:MONTICELLO DENTAL CENTER PLLC
Entity Type:Organization
Organization Name:MONTICELLO DENTAL CENTER PLLC
Other - Org Name:STAR CITY DENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:D
Authorized Official - Last Name:MATONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-205-1084
Mailing Address - Street 1:PO BOX 241785
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-0014
Mailing Address - Country:US
Mailing Address - Phone:501-205-1084
Mailing Address - Fax:
Practice Address - Street 1:112 W BRADLEY ST
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667-5114
Practice Address - Country:US
Practice Address - Phone:870-628-5131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty