Provider Demographics
NPI:1962933887
Name:HUNTINGTON DENTAL PLLC
Entity type:Organization
Organization Name:HUNTINGTON DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-781-2777
Mailing Address - Street 1:PO BOX 3450
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-3450
Mailing Address - Country:US
Mailing Address - Phone:501-781-2777
Mailing Address - Fax:
Practice Address - Street 1:6353 E PEA RIDGE RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2525
Practice Address - Country:US
Practice Address - Phone:304-736-4794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty