Provider Demographics
NPI:1720369093
Name:LILLIAM M PRADO DDS
Entity Type:Organization
Organization Name:LILLIAM M PRADO DDS
Other - Org Name:FAITH DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRADO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-565-3009
Mailing Address - Street 1:7301 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-4436
Mailing Address - Country:US
Mailing Address - Phone:501-565-3009
Mailing Address - Fax:501-565-3511
Practice Address - Street 1:7301 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4436
Practice Address - Country:US
Practice Address - Phone:501-565-3009
Practice Address - Fax:501-565-3511
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LILLIAM PRADO D.D.S PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR35541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187151631Medicaid