Provider Demographics
NPI:1992042386
Name:INTERDISCIPLINARY DENTAL THERAPY, P.A.
Entity Type:Organization
Organization Name:INTERDISCIPLINARY DENTAL THERAPY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTGOMERY
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:HEATHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-856-5588
Mailing Address - Street 1:9200 CHICOT RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-6107
Mailing Address - Country:US
Mailing Address - Phone:501-562-3029
Mailing Address - Fax:501-568-1823
Practice Address - Street 1:9200 CHICOT RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-6107
Practice Address - Country:US
Practice Address - Phone:501-562-3029
Practice Address - Fax:501-568-1823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-06
Last Update Date:2013-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR33331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161458608Medicaid