Provider Demographics
NPI:1740435312
Name:ARKANSAS DENTAL PROFESSIONALS, MONGRAIN, P.A
Entity type:Organization
Organization Name:ARKANSAS DENTAL PROFESSIONALS, MONGRAIN, P.A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5699
Mailing Address - Street 1:3003 TWIN RIVERS DR
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-4219
Mailing Address - Country:US
Mailing Address - Phone:870-246-2242
Mailing Address - Fax:870-246-2495
Practice Address - Street 1:3003 TWIN RIVERS DR
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4219
Practice Address - Country:US
Practice Address - Phone:870-246-2242
Practice Address - Fax:870-246-2495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2256122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR172175631Medicaid