Provider Demographics
NPI:1932643236
Name:AXPM- JACKSONVILLE DENTAL PLLC
Entity Type:Organization
Organization Name:AXPM- JACKSONVILLE DENTAL PLLC
Other - Org Name:ROCK FAMILY DENTAL- JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-781-2777
Mailing Address - Street 1:PO BOX 3450
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-3450
Mailing Address - Country:US
Mailing Address - Phone:501-781-2777
Mailing Address - Fax:501-781-2778
Practice Address - Street 1:1405 BRADEN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3720
Practice Address - Country:US
Practice Address - Phone:501-241-2345
Practice Address - Fax:501-985-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty