Provider Demographics
NPI:1922485507
Name:PERSENAIRE, MITCHELL (DMD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:PERSENAIRE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3394 N FUTRALL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4057
Mailing Address - Country:US
Mailing Address - Phone:479-582-3360
Mailing Address - Fax:479-582-3466
Practice Address - Street 1:3394 N FUTRALL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4057
Practice Address - Country:US
Practice Address - Phone:479-582-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-02
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4288122300000X
AR201223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist