Provider Demographics
NPI:1669736336
Name:ROSS, DERRICK KYLE (DMD)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:KYLE
Last Name:ROSS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 TWIN RIVERS DR
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-4212
Mailing Address - Country:US
Mailing Address - Phone:870-703-3194
Mailing Address - Fax:
Practice Address - Street 1:2840 TWIN RIVERS DR
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4212
Practice Address - Country:US
Practice Address - Phone:870-246-9847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR38741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice