Provider Demographics
NPI:1336875558
Name:FULL THROTTLE DENTAL, PLLC
Entity type:Organization
Organization Name:FULL THROTTLE DENTAL, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-336-3732
Mailing Address - Street 1:1804 OLD GREENSBORO RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-0003
Mailing Address - Country:US
Mailing Address - Phone:870-336-3732
Mailing Address - Fax:
Practice Address - Street 1:6630 SUMMER KNOLL CIR STE 103
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-2926
Practice Address - Country:US
Practice Address - Phone:901-377-5060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-29
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty