Provider Demographics
NPI:1649431370
Name:PEDIATRIC DENTISTRY OF EASTERN ARKANSAS
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY OF EASTERN ARKANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OM
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-735-2298
Mailing Address - Street 1:126 W BOND AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-3909
Mailing Address - Country:US
Mailing Address - Phone:870-735-2298
Mailing Address - Fax:870-735-7853
Practice Address - Street 1:126 W BOND AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3909
Practice Address - Country:US
Practice Address - Phone:870-735-2298
Practice Address - Fax:870-735-7853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167735631Medicaid