Provider Demographics
NPI:1629562616
Name:AT EASE DENTAL, LLC
Entity Type:Organization
Organization Name:AT EASE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:TRISTAN RAY
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-871-4313
Mailing Address - Street 1:513 S DODSON RD APT Q4
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-7318
Mailing Address - Country:US
Mailing Address - Phone:479-871-4313
Mailing Address - Fax:
Practice Address - Street 1:701 NW MCNELLY RD STE 13
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-9160
Practice Address - Country:US
Practice Address - Phone:479-553-9225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4275122300000X
OK7052122300000X
MO2018018775122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty