Provider Demographics
NPI:1871610857
Name:KENNETH E PEARSON DDS PA
Entity type:Organization
Organization Name:KENNETH E PEARSON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-221-1200
Mailing Address - Street 1:12921 CANTRELL RD SUITE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223
Mailing Address - Country:US
Mailing Address - Phone:501-221-1200
Mailing Address - Fax:501-221-1326
Practice Address - Street 1:12921 CANTRELL RD SUITE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223
Practice Address - Country:US
Practice Address - Phone:501-221-1200
Practice Address - Fax:501-221-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26941223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
56311OtherBCBS
AR111380608Medicaid
696033OtherUNITED CONCORDIA