Provider Demographics
NPI:1831334457
Name:CLARKSVILLE DENTISTRY, INC.
Entity type:Organization
Organization Name:CLARKSVILLE DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:K
Authorized Official - Last Name:MUNCY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-754-8818
Mailing Address - Street 1:307 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3725
Mailing Address - Country:US
Mailing Address - Phone:479-754-8818
Mailing Address - Fax:479-754-6790
Practice Address - Street 1:307 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3725
Practice Address - Country:US
Practice Address - Phone:479-754-8818
Practice Address - Fax:479-754-6790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2332261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR118410608Medicaid