Provider Demographics
NPI:1164221834
Name:MAIN STREET FAMILY DENTAL
Entity type:Organization
Organization Name:MAIN STREET FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:B
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-367-7636
Mailing Address - Street 1:433 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-4817
Mailing Address - Country:US
Mailing Address - Phone:870-367-7636
Mailing Address - Fax:870-460-0233
Practice Address - Street 1:433 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-4817
Practice Address - Country:US
Practice Address - Phone:870-367-7636
Practice Address - Fax:870-460-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental