Provider Demographics
NPI:1689085730
Name:RIVER VALLEY MOBILE DENTAL CLINIC
Entity Type:Organization
Organization Name:RIVER VALLEY MOBILE DENTAL CLINIC
Other - Org Name:WARD W. CLEMMONS IMPLANT & COMPREHENSIVE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLEMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-434-6894
Mailing Address - Street 1:3600 OLD GREENWOOD RD STE 2
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5930
Mailing Address - Country:US
Mailing Address - Phone:479-434-6894
Mailing Address - Fax:479-434-6896
Practice Address - Street 1:3600 OLD GREENWOOD RD STE 2
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5930
Practice Address - Country:US
Practice Address - Phone:479-434-6894
Practice Address - Fax:479-434-6896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty