Provider Demographics
NPI:1689103038
Name:POWELL, CREIGHTON DESHAWN
Entity Type:Individual
Prefix:
First Name:CREIGHTON
Middle Name:DESHAWN
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 RED WOLF BLVD STE I
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5453
Mailing Address - Country:US
Mailing Address - Phone:870-336-0543
Mailing Address - Fax:870-336-0061
Practice Address - Street 1:1699 STADIUM BLVD SUITE I
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-336-0543
Practice Address - Fax:870-336-0061
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR41691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR168292631Medicaid