Provider Demographics
NPI:1649654856
Name:AXPM-BRYANT PEDO LLC
Entity type:Organization
Organization Name:AXPM-BRYANT PEDO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-781-2777
Mailing Address - Street 1:PO BOX 24470
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72221-4470
Mailing Address - Country:US
Mailing Address - Phone:501-781-2777
Mailing Address - Fax:501-781-2778
Practice Address - Street 1:7409 ALCOA RD
Practice Address - Street 2:#5
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-6214
Practice Address - Country:US
Practice Address - Phone:501-315-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty