Provider Demographics
NPI:1174768758
Name:ARKANSAS RIVER VALLEY DENTISTRY
Entity type:Organization
Organization Name:ARKANSAS RIVER VALLEY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-754-3357
Mailing Address - Street 1:1101 E POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-4420
Mailing Address - Country:US
Mailing Address - Phone:479-754-3357
Mailing Address - Fax:479-754-0167
Practice Address - Street 1:1101 E POPLAR ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-4420
Practice Address - Country:US
Practice Address - Phone:479-754-3357
Practice Address - Fax:479-754-0167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105845608Medicaid