Provider Demographics
NPI:1336554831
Name:ARKANSAS ORTHODONTIC SPECIALIST INC
Entity Type:Organization
Organization Name:ARKANSAS ORTHODONTIC SPECIALIST INC
Other - Org Name:WHITLOCK ORTHODONTICS OF FORT SMITH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOLDING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:479-717-1047
Mailing Address - Street 1:PO BOX 1136
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72145-1136
Mailing Address - Country:US
Mailing Address - Phone:479-717-1047
Mailing Address - Fax:479-717-1047
Practice Address - Street 1:8309 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6141
Practice Address - Country:US
Practice Address - Phone:479-717-1171
Practice Address - Fax:479-717-1047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARKANSAS ORTHODONTIC SPECIALIST INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-24
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty