Provider Demographics
NPI:1396949343
Name:J MARK FALKOFF DDS PA
Entity type:Organization
Organization Name:J MARK FALKOFF DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:FALKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-234-0450
Mailing Address - Street 1:912 N JACKSON
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753
Mailing Address - Country:US
Mailing Address - Phone:870-234-0450
Mailing Address - Fax:870-234-5662
Practice Address - Street 1:912 N JACKSON
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753
Practice Address - Country:US
Practice Address - Phone:870-234-0450
Practice Address - Fax:870-234-5662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2640122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR849579OtherUNITED CONCORDIA
AR58827OtherABCBS