Provider Demographics
NPI:1336409333
Name:MIDTOWN DENTAL
Entity Type:Organization
Organization Name:MIDTOWN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:AEBERSOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-664-1733
Mailing Address - Street 1:814 N. UNIVERSITY AVE.
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-664-5555
Mailing Address - Fax:501-664-1759
Practice Address - Street 1:814 NORTH UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-664-5555
Practice Address - Fax:501-664-1759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185631631Medicaid