Provider Demographics
NPI:1316234636
Name:SMILES OF ARKANSAS DENTAL CENTER, PLLC
Entity type:Organization
Organization Name:SMILES OF ARKANSAS DENTAL CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-777-6453
Mailing Address - Street 1:1621 ARKANSAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1607
Mailing Address - Country:US
Mailing Address - Phone:870-774-7645
Mailing Address - Fax:870-773-7647
Practice Address - Street 1:1621 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1607
Practice Address - Country:US
Practice Address - Phone:870-774-7645
Practice Address - Fax:870-773-7647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR31771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty