Provider Demographics
NPI:1750410569
Name:SUMMITT, JAMES ALFRED (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ALFRED
Last Name:SUMMITT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 ANGELINE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-8601
Mailing Address - Country:US
Mailing Address - Phone:501-336-8863
Mailing Address - Fax:501-932-0227
Practice Address - Street 1:830 N CREEK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4711
Practice Address - Country:US
Practice Address - Phone:501-932-0559
Practice Address - Fax:501-932-0227
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112154608Medicaid