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Organization
MAMMOTH SPRING DENTAL CLINIC, LLC
Active
Organization
MAMMOTH SPRING DENTAL CLINIC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL D. KERSEY DDS (MEMBER)
(870) 625-3262
Entity
Organization
Contact information
Practice address
180 MAIN STREET, MAMMOTH SPRING, AR 72554
(870) 625-3262
(870) 625-3673
Mailing address
P.O. BOX 128, MAMMOTH SPRING, AR 72554
(870) 625-3262
(870) 625-3673
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
2661
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
102276608
—
AR
05
—
402069306
—
MO
01
—
56593
BLUE CROSS BLUE SHIELD
AR
01
—
889-284
UNITED CONCORDIA
AR
Enumeration date
01/21/2010
Last updated
01/21/2010
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