Provider Demographics
NPI:1194157818
Name:SUMMIT DENTAL CARE
Entity type:Organization
Organization Name:SUMMIT DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:NEILSON
Authorized Official - Last Name:JEPPSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-524-9379
Mailing Address - Street 1:3860 HIGHWAY 412 E STE F
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-8499
Mailing Address - Country:US
Mailing Address - Phone:479-524-9379
Mailing Address - Fax:479-524-0976
Practice Address - Street 1:3860 HIGHWAY 412 E STE F
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-8499
Practice Address - Country:US
Practice Address - Phone:479-524-9379
Practice Address - Fax:479-524-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR37171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180792608Medicaid
OK200268160AMedicaid