Provider Demographics
NPI:1972930295
Name:MAIN STREET DENTAL PLLC
Entity type:Organization
Organization Name:MAIN STREET DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-254-6899
Mailing Address - Street 1:312 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-5903
Mailing Address - Country:US
Mailing Address - Phone:479-254-6899
Mailing Address - Fax:479-254-6749
Practice Address - Street 1:312 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5903
Practice Address - Country:US
Practice Address - Phone:479-254-6899
Practice Address - Fax:479-254-6749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3599261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental