Provider Demographics
NPI:1861667131
Name:SPADES DENTAL CARE, P.A.
Entity Type:Organization
Organization Name:SPADES DENTAL CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:SPADES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-910-0000
Mailing Address - Street 1:900 SOUTHWEST DR
Mailing Address - Street 2:STE C&D
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7051
Mailing Address - Country:US
Mailing Address - Phone:870-910-0000
Mailing Address - Fax:870-910-3500
Practice Address - Street 1:900 SOUTHWEST DR
Practice Address - Street 2:STE C&D
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7051
Practice Address - Country:US
Practice Address - Phone:870-910-0000
Practice Address - Fax:870-910-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR32991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U366OtherARKANSAS BLUE CROSS AND BLUE SHIELD
AR136699608Medicaid