Basic Information
Provider Information
NPI: 1447892377
EntityType: 2
ReplacementNPI:  
OrganizationName: MC DENTAL LLC
LastName:  
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Mailing Information
Address1: 702 SW 8TH ST
Address2:  
City: BENTONVILLE
State: AR
PostalCode: 727160445
CountryCode: US
TelephoneNumber: 4792041258
FaxNumber: 4792774331
Practice Location
Address1: 448 WEST BELMONT DRIVE
Address2:  
City: CALHOUN
State: GA
PostalCode: 307013016
CountryCode: US
TelephoneNumber: 7622046433
FaxNumber: 7066298126
Other Information
ProviderEnumerationDate: 10/11/2019
LastUpdateDate: 12/07/2021
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: CHUNG
AuthorizedOfficialFirstName: THERESA
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AuthorizedOfficialTitleorPosition: PRINCIPAL- WALMART HEALTH DENTAL
AuthorizedOfficialTelephone: 7622046433
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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NPICertificationDate: 12/07/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X  Y193400000X SINGLE SPECIALTY GROUPDental ProvidersDentist 

No ID Information.


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