Provider Demographics
NPI:1851750897
Name:MONTGOMERY HEATHMAN DDS, PA
Entity Type:Organization
Organization Name:MONTGOMERY HEATHMAN DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTGOMERY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HEATHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-856-5588
Mailing Address - Street 1:12501 CANTRELL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-1639
Mailing Address - Country:US
Mailing Address - Phone:501-223-3838
Mailing Address - Fax:501-223-2554
Practice Address - Street 1:12501 CANTRELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-1639
Practice Address - Country:US
Practice Address - Phone:501-223-3838
Practice Address - Fax:501-223-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3333122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161458608Medicaid