Provider Demographics
NPI:1194886291
Name:W.DARREL FAIN D.D.S. P.A.
Entity type:Organization
Organization Name:W.DARREL FAIN D.D.S. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DARREL
Authorized Official - Last Name:FAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-887-5051
Mailing Address - Street 1:419 E 6TH ST S
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-2432
Mailing Address - Country:US
Mailing Address - Phone:870-887-5051
Mailing Address - Fax:870-887-6400
Practice Address - Street 1:419 E 6TH ST S
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857-2432
Practice Address - Country:US
Practice Address - Phone:870-887-5051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR21141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116984831Medicaid
AR2114OtherDELTA DENTAL
AR58267OtherBLUE CROSS BLUE SHIELD