Provider Demographics
NPI:1790992758
Name:PERSHING DENTAL CLINIC
Entity Type:Organization
Organization Name:PERSHING DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-753-2800
Mailing Address - Street 1:520 W PERSHING BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-2148
Mailing Address - Country:US
Mailing Address - Phone:501-753-2800
Mailing Address - Fax:501-907-6456
Practice Address - Street 1:520 W PERSHING BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-2100
Practice Address - Country:US
Practice Address - Phone:501-753-2800
Practice Address - Fax:501-907-6456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1902122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty