Provider Demographics
NPI:1427700111
Name:NORTHEAST ARKANSAS OMFS, PLLC
Entity type:Organization
Organization Name:NORTHEAST ARKANSAS OMFS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-931-3000
Mailing Address - Street 1:2609 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7227
Mailing Address - Country:US
Mailing Address - Phone:870-931-3000
Mailing Address - Fax:870-931-0190
Practice Address - Street 1:2609 BROWNS LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7227
Practice Address - Country:US
Practice Address - Phone:870-931-3000
Practice Address - Fax:870-931-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR225890679Medicaid