Provider Demographics
NPI:1508756073
Name:17 EAGLE VILONIA PROFESSIONAL LLC
Entity type:Organization
Organization Name:17 EAGLE VILONIA PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORSYTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-796-3903
Mailing Address - Street 1:17 EAGLE PARK DR
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173-9050
Mailing Address - Country:US
Mailing Address - Phone:501-796-3903
Mailing Address - Fax:
Practice Address - Street 1:17 EAGLE PARK DR
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173-9050
Practice Address - Country:US
Practice Address - Phone:501-796-3903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty