Provider Demographics
NPI:1528253416
Name:NORTHWEST ARKANSAS ENDODONTIC SPECIALISTS, PA
Entity type:Organization
Organization Name:NORTHWEST ARKANSAS ENDODONTIC SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:TINNIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:479-521-2814
Mailing Address - Street 1:1831 N GREEN ACRES RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2615
Mailing Address - Country:US
Mailing Address - Phone:479-521-2814
Mailing Address - Fax:479-521-5842
Practice Address - Street 1:1831 N GREEN ACRES RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2615
Practice Address - Country:US
Practice Address - Phone:479-521-2814
Practice Address - Fax:479-521-5842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR19981223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty