Provider Demographics
NPI:1942373576
Name:WHARTON-PALMER, MICHAEL GRAHAM (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GRAHAM
Last Name:WHARTON-PALMER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 ARKANSAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1610
Mailing Address - Country:US
Mailing Address - Phone:870-774-3278
Mailing Address - Fax:870-772-4593
Practice Address - Street 1:1702 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1610
Practice Address - Country:US
Practice Address - Phone:870-774-3278
Practice Address - Fax:870-772-4593
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58332OtherBLUE CROSS AND BLUE SHEIL
AR1108992OtherINSURANCE COMPANY