Provider Demographics
NPI:1952431868
Name:ARKANSAS FAMILY DENTAL, PA
Entity Type:Organization
Organization Name:ARKANSAS FAMILY DENTAL, PA
Other - Org Name:TINA H. NICHOLS, DDS, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-312-7576
Mailing Address - Street 1:13600 DAVID O. DODD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210
Mailing Address - Country:US
Mailing Address - Phone:501-312-7576
Mailing Address - Fax:501-687-0669
Practice Address - Street 1:13600 DAVID O. DODD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210
Practice Address - Country:US
Practice Address - Phone:501-312-7576
Practice Address - Fax:501-687-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33111223G0001X
AR34351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR181913631Medicaid