Provider Demographics
NPI:1932448032
Name:D MICHAEL DERUYTER D D S INC
Entity Type:Organization
Organization Name:D MICHAEL DERUYTER D D S INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DERUYTER
Authorized Official - Suffix:
Authorized Official - Credentials:D D S
Authorized Official - Phone:870-867-4110
Mailing Address - Street 1:3447 HIGHWAY 270 E
Mailing Address - Street 2:
Mailing Address - City:MOUNT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957-8092
Mailing Address - Country:US
Mailing Address - Phone:870-867-4110
Mailing Address - Fax:870-867-2207
Practice Address - Street 1:3447 HIGHWAY 270 E
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957-8092
Practice Address - Country:US
Practice Address - Phone:870-867-4110
Practice Address - Fax:870-867-2207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR181483608Medicaid