Provider Demographics
NPI:1003173634
Name:KIDZ CHOICE DENTAL PA
Entity type:Organization
Organization Name:KIDZ CHOICE DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-327-2030
Mailing Address - Street 1:2415 PRINCE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3746
Mailing Address - Country:US
Mailing Address - Phone:501-327-2030
Mailing Address - Fax:501-327-0242
Practice Address - Street 1:2415 PRINCE ST STE 105
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3746
Practice Address - Country:US
Practice Address - Phone:501-327-2030
Practice Address - Fax:501-327-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2841261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental