Provider Demographics
NPI:1922373794
Name:AR DENTAL & TMJ - JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:AR DENTAL & TMJ - JACKSONVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUPAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-225-1577
Mailing Address - Street 1:1426 BRADEN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-3721
Mailing Address - Country:US
Mailing Address - Phone:501-982-3777
Mailing Address - Fax:501-982-3433
Practice Address - Street 1:1426 BRADEN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3721
Practice Address - Country:US
Practice Address - Phone:501-982-3777
Practice Address - Fax:501-982-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty