Provider Demographics
NPI:1720417314
Name:SUMMIT DENTAL, INC.
Entity Type:Organization
Organization Name:SUMMIT DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HALBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-227-0500
Mailing Address - Street 1:12120 COL GLENN RD
Mailing Address - Street 2:SUITE 6600
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-2824
Mailing Address - Country:US
Mailing Address - Phone:501-227-0500
Mailing Address - Fax:501-227-0503
Practice Address - Street 1:12120 COL GLENN RD
Practice Address - Street 2:SUITE 6600
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-2824
Practice Address - Country:US
Practice Address - Phone:501-227-0500
Practice Address - Fax:501-227-0503
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT DENTAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1780939678OtherLICENSE 3917