Provider Demographics
NPI:1255769535
Name:DALLAS AVENUE DENTAL CARE, INC.
Entity type:Organization
Organization Name:DALLAS AVENUE DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAROSY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FAGD
Authorized Official - Phone:479-394-7800
Mailing Address - Street 1:400 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-4604
Mailing Address - Country:US
Mailing Address - Phone:479-394-7800
Mailing Address - Fax:479-394-7803
Practice Address - Street 1:400 PINE AVE
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-4604
Practice Address - Country:US
Practice Address - Phone:479-394-7800
Practice Address - Fax:479-394-7803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2933332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment