Provider Demographics
NPI:1992078125
Name:NEIGHBORHOOD DENTAL SERVICES OF NWA, PLLC
Entity type:Organization
Organization Name:NEIGHBORHOOD DENTAL SERVICES OF NWA, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER AND SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MAHON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-619-9052
Mailing Address - Street 1:1104 POPLAR PL
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-4249
Mailing Address - Country:US
Mailing Address - Phone:479-619-9052
Mailing Address - Fax:479-636-5154
Practice Address - Street 1:1909 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5601
Practice Address - Country:US
Practice Address - Phone:479-273-9302
Practice Address - Fax:479-268-4630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-19
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2401122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190167631Medicaid