Provider Demographics
NPI:1588087993
Name:AUSTIN FAMILY DENTISTY OF LITTLE ROCK
Entity type:Organization
Organization Name:AUSTIN FAMILY DENTISTY OF LITTLE ROCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-223-9489
Mailing Address - Street 1:11211 CANTRELL RD
Mailing Address - Street 2:STE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-1819
Mailing Address - Country:US
Mailing Address - Phone:501-223-9489
Mailing Address - Fax:
Practice Address - Street 1:11211 CANTRELL RD
Practice Address - Street 2:STE 200
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-1819
Practice Address - Country:US
Practice Address - Phone:501-223-9489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUSTIN FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR6869920001OtherMEDICARE PTAN