Provider Demographics
NPI:1922292531
Name:PEDIATRIC DENTISTRY OF EASTERN ARKANSAS
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF EASTERN ARKANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDA/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAORN
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:FRANKS
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:870-630-1500
Mailing Address - Street 1:4941 N WASHINGTON
Mailing Address - Street 2:HIGHWAY 1
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-3022
Mailing Address - Country:US
Mailing Address - Phone:870-630-1500
Mailing Address - Fax:870-630-6405
Practice Address - Street 1:4941 N WASHINGTON HWY 1
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-3022
Practice Address - Country:US
Practice Address - Phone:870-630-1500
Practice Address - Fax:870-630-6405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR59632OtherBLUE CROSS BLUE SHIELD
AR862131OtherUNITED CONCORDIA