Provider Demographics
NPI:1245829027
Name:ORAL SURGERY OF CENTRAL ARKANSAS
Entity type:Organization
Organization Name:ORAL SURGERY OF CENTRAL ARKANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:013-275-2555
Mailing Address - Street 1:4701 FAIRWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8069
Mailing Address - Country:US
Mailing Address - Phone:501-327-5255
Mailing Address - Fax:501-791-2824
Practice Address - Street 1:4701 FAIRWAY AVE STE D
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8069
Practice Address - Country:US
Practice Address - Phone:501-791-7600
Practice Address - Fax:501-791-2824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200352679Medicaid