Provider Demographics
NPI:1215947304
Name:MILLENNIUM DENTAL, PLLC
Entity type:Organization
Organization Name:MILLENNIUM DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-521-4440
Mailing Address - Street 1:2827 E MILLENNIUM PL STE 3
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6528
Mailing Address - Country:US
Mailing Address - Phone:479-521-4440
Mailing Address - Fax:479-521-4443
Practice Address - Street 1:2827 E MILLENNIUM PL STE 3
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6528
Practice Address - Country:US
Practice Address - Phone:479-521-4440
Practice Address - Fax:479-521-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR32161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1790011OtherUNITED CONCORDIA ID
AR5T702OtherBLUE CROSS BLUE SHIELD ID
ARAR3216OtherSTATE LICENSE NUMBER