Provider Demographics
NPI:1306060850
Name:ICD INC
Entity type:Organization
Organization Name:ICD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DEATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-425-1441
Mailing Address - Street 1:320 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-4416
Mailing Address - Country:US
Mailing Address - Phone:870-425-1441
Mailing Address - Fax:870-425-1445
Practice Address - Street 1:320 E 7TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-4416
Practice Address - Country:US
Practice Address - Phone:870-425-1441
Practice Address - Fax:870-425-1445
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ICD INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3573122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161452631Medicaid