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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