Provider Demographics
NPI:1871822163
Name:TOLAND DENTAL
Entity Type:Organization
Organization Name:TOLAND DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:870-238-0400
Mailing Address - Street 1:2100 KILLOUGH RD N
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-1009
Mailing Address - Country:US
Mailing Address - Phone:870-238-0400
Mailing Address - Fax:870-238-0417
Practice Address - Street 1:2100 KILLOUGH RD N
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-1009
Practice Address - Country:US
Practice Address - Phone:870-238-0400
Practice Address - Fax:870-238-0417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102049608Medicaid
779622OtherUNITED CONCORDIA INSURANCE
58929OtherBLUE CROSS BLUE SHIELD INSURANCE