Provider Demographics
NPI:1790909752
Name:KEN WOOD, D.D.S. M.S. CHILDRENS DENTISTRY
Entity Type:Organization
Organization Name:KEN WOOD, D.D.S. M.S. CHILDRENS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:I
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:870-931-5437
Mailing Address - Street 1:PO BOX 1369
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1369
Mailing Address - Country:US
Mailing Address - Phone:870-931-5437
Mailing Address - Fax:870-931-9781
Practice Address - Street 1:2702 S CULBERHOUSE ST
Practice Address - Street 2:SUITE Q
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7132
Practice Address - Country:US
Practice Address - Phone:870-931-5437
Practice Address - Fax:870-931-9781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR27381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR828134OtherUNITED CONCORDIA
AR59239OtherARKANSAS BLUE CROSS BLUE