Provider Demographics
NPI:1023349651
Name:MAMMOTH SPRING DENTAL CLINIC, LLC
Entity type:Organization
Organization Name:MAMMOTH SPRING DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:KERSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-625-3262
Mailing Address - Street 1:P.O. BOX 128
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH SPRING
Mailing Address - State:AR
Mailing Address - Zip Code:72554
Mailing Address - Country:US
Mailing Address - Phone:870-625-3262
Mailing Address - Fax:870-625-3673
Practice Address - Street 1:180 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MAMMOTH SPRING
Practice Address - State:AR
Practice Address - Zip Code:72554
Practice Address - Country:US
Practice Address - Phone:870-625-3262
Practice Address - Fax:870-625-3673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO402069306Medicaid
AR889-284OtherUNITED CONCORDIA
AR56593OtherBLUE CROSS BLUE SHIELD
AR102276608Medicaid