Provider Demographics
NPI:1255885307
Name:SOUTHEAST FAMILY DENTISTRY PLLC
Entity type:Organization
Organization Name:SOUTHEAST FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LALLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-222-3926
Mailing Address - Street 1:601 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MC GEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-2005
Mailing Address - Country:US
Mailing Address - Phone:870-222-3926
Mailing Address - Fax:870-222-4002
Practice Address - Street 1:601 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MC GEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-2005
Practice Address - Country:US
Practice Address - Phone:870-222-3926
Practice Address - Fax:870-222-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR41061223G0001X
AR21641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty