Provider Demographics
NPI:1619960440
Name:G FRIEND DDS MS & M WILSON DDS MS PA
Entity Type:Organization
Organization Name:G FRIEND DDS MS & M WILSON DDS MS PA
Other - Org Name:CONWAY PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:FRIEND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:501-730-0375
Mailing Address - Street 1:PO BOX 11020
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-0018
Mailing Address - Country:US
Mailing Address - Phone:501-730-0375
Mailing Address - Fax:501-730-0335
Practice Address - Street 1:2700 ALLYSON LANE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-730-0375
Practice Address - Fax:501-730-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR27931223P0221X
AR34751223P0221X
AR28171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty