Provider Demographics
NPI:1609025451
Name:MARY ANN WEATHERFORD DDS, PA
Entity Type:Organization
Organization Name:MARY ANN WEATHERFORD DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WEATHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:870-697-2606
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:620 JULIA
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-0554
Mailing Address - Country:US
Mailing Address - Phone:870-238-2600
Mailing Address - Fax:870-238-5522
Practice Address - Street 1:620 JULIA AVE E
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3504
Practice Address - Country:US
Practice Address - Phone:870-238-2600
Practice Address - Fax:870-238-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty