Provider Demographics
NPI:1255415956
Name:AUSTIN FAMILY DENTISTRY PA
Entity type:Organization
Organization Name:AUSTIN FAMILY DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-851-3262
Mailing Address - Street 1:3201 CLUB MANOR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113
Mailing Address - Country:US
Mailing Address - Phone:501-851-3262
Mailing Address - Fax:501-851-3766
Practice Address - Street 1:3201 CLUB MANOR
Practice Address - Street 2:SUITE A
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113
Practice Address - Country:US
Practice Address - Phone:501-851-3262
Practice Address - Fax:501-851-3766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR3057122300000X
ARAR3521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1871870OtherUCCI DR CLINT FULKS
828326OtherUCCI DR BRYAN A AUSTIN
AR58662OtherBCBS