Provider Demographics
NPI:1063957728
Name:AXPM- HIGHLAND DENTAL PLLC
Entity type:Organization
Organization Name:AXPM- HIGHLAND DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-781-2777
Mailing Address - Street 1:PO BOX 3450
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-3450
Mailing Address - Country:US
Mailing Address - Phone:501-781-2777
Mailing Address - Fax:
Practice Address - Street 1:1474 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9170
Practice Address - Country:US
Practice Address - Phone:501-781-2777
Practice Address - Fax:501-781-2778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty