Provider Demographics
NPI:1912500364
Name:RONNIE L FAULKNER, DDS, PA
Entity Type:Organization
Organization Name:RONNIE L FAULKNER, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDE
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-276-3432
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:MOUNT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957-0901
Mailing Address - Country:US
Mailing Address - Phone:870-867-3432
Mailing Address - Fax:870-867-3783
Practice Address - Street 1:138 HIGHWAY 270 E
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957-9409
Practice Address - Country:US
Practice Address - Phone:870-867-3432
Practice Address - Fax:870-867-3783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111161608Medicaid