Provider Demographics
NPI:1881789865
Name:TERRY L. FIDDLER, D.D.S., P.A.
Entity type:Organization
Organization Name:TERRY L. FIDDLER, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SISSY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-327-7778
Mailing Address - Street 1:562 LOCUST STREET
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-327-7778
Mailing Address - Fax:
Practice Address - Street 1:562 LOCUST STREET
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-327-7778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR21151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR858661OtherUNITED CONCORDIA
AR58493OtherBLUE CROSS BLUE SHIELD