Provider Demographics
NPI:1124285689
Name:FAITH DENTAL CLINIC
Entity type:Organization
Organization Name:FAITH DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LILLIAM
Authorized Official - Middle Name:MARGARITA
Authorized Official - Last Name:PRADO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-562-1665
Mailing Address - Street 1:8211 GEYER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-4952
Mailing Address - Country:US
Mailing Address - Phone:501-562-1665
Mailing Address - Fax:501-562-1667
Practice Address - Street 1:8211 GEYER SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4952
Practice Address - Country:US
Practice Address - Phone:501-562-1665
Practice Address - Fax:501-562-1667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163107608Medicaid
ARB/S 5Y875OtherBLUE CROSS BLUE SHIELD