Provider Demographics
NPI:1992810196
Name:PARKLANE FAMILY DENTAL
Entity type:Organization
Organization Name:PARKLANE FAMILY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:LIGGETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-782-0080
Mailing Address - Street 1:3200 ROGERS AVE
Mailing Address - Street 2:STE 111
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:479-782-0080
Mailing Address - Fax:479-783-8580
Practice Address - Street 1:3200 ROGERS AVE
Practice Address - Street 2:STE 111
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-782-0080
Practice Address - Fax:479-783-8580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2055122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1464220OtherUNITED CONCORDIA
AR5C819OtherBCBS