Provider Demographics
NPI:1194745745
Name:LALLY, JOHN M (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:LALLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MCGEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-2005
Mailing Address - Country:US
Mailing Address - Phone:870-222-3926
Mailing Address - Fax:870-222-4002
Practice Address - Street 1:601 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MCGEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-2005
Practice Address - Country:US
Practice Address - Phone:870-222-3926
Practice Address - Fax:870-222-4002
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR21641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139106631Medicaid
AR000834033OtherUNITED CONCORDIA PROVIDER
AR58382OtherBLUE CROSS BLUE SHIELD
AR000834033OtherUNITED CONCORDIA PROVIDER