Provider Demographics
NPI:1780095646
Name:DALLAS STREET DENTAL
Entity type:Organization
Organization Name:DALLAS STREET DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIGON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-452-6600
Mailing Address - Street 1:8020 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4277
Mailing Address - Country:US
Mailing Address - Phone:479-452-6600
Mailing Address - Fax:479-452-6692
Practice Address - Street 1:8020 DALLAS ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4277
Practice Address - Country:US
Practice Address - Phone:479-452-6600
Practice Address - Fax:479-452-6692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3119261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental