Provider Demographics
NPI:1053418038
Name:NORTHWEST ARKANSAS PERIODONTAL ASSOCIATES, PLLC
Entity type:Organization
Organization Name:NORTHWEST ARKANSAS PERIODONTAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:RENEGAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-521-6400
Mailing Address - Street 1:1831 N GREEN ACRES RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2615
Mailing Address - Country:US
Mailing Address - Phone:479-521-6400
Mailing Address - Fax:479-521-0164
Practice Address - Street 1:1831 N GREEN ACRES RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2615
Practice Address - Country:US
Practice Address - Phone:479-521-6400
Practice Address - Fax:479-521-0164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58605OtherBLUE CROSS BLUE SHIELD