Provider Demographics
NPI:1780086454
Name:OMEGA FAMILY DENTAL
Entity type:Organization
Organization Name:OMEGA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-366-0097
Mailing Address - Street 1:14309 CANTRELL RD STE 6
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-4230
Mailing Address - Country:US
Mailing Address - Phone:501-228-6360
Mailing Address - Fax:
Practice Address - Street 1:14309 CANTRELL RD STE 6
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-4230
Practice Address - Country:US
Practice Address - Phone:501-228-6360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty