Provider Demographics
NPI:1487775011
Name:RIVER VALLEY PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:RIVER VALLEY PEDIATRIC DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-783-4182
Mailing Address - Street 1:417 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4625
Mailing Address - Country:US
Mailing Address - Phone:479-783-4182
Mailing Address - Fax:479-783-4379
Practice Address - Street 1:417 S 16TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4625
Practice Address - Country:US
Practice Address - Phone:479-783-4182
Practice Address - Fax:479-783-4379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131026608Medicaid
AR155183631Medicaid