Provider Demographics
NPI:1942762273
Name:CHILDRENS DENTAL CLINIC OF JONESBORO
Entity Type:Organization
Organization Name:CHILDRENS DENTAL CLINIC OF JONESBORO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-897-9465
Mailing Address - Street 1:217 E CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 E CHERRY AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3372
Practice Address - Country:US
Practice Address - Phone:870-897-2489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1023240595Medicaid