Provider Demographics
NPI:1932359478
Name:ADAMS, DALE BRENT
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:BRENT
Last Name:ADAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 ANVIL DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-8687
Mailing Address - Country:US
Mailing Address - Phone:870-391-2231
Mailing Address - Fax:
Practice Address - Street 1:2313 ANVIL DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-8687
Practice Address - Country:US
Practice Address - Phone:870-391-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-20
Last Update Date:2008-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
AR302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169609784Medicaid