1114260080 NPI number — BETHEL BURRIS OLIVER PLLC

Table of content: (NPI 1114260080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114260080 NPI number — BETHEL BURRIS OLIVER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHEL BURRIS OLIVER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ARKANSAS DENTISTRY AND BRACES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114260080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3782 N FRONT ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-5128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-443-1705
Provider Business Mailing Address Fax Number:
479-443-1586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 SE WALTON BLVD
Provider Second Line Business Practice Location Address:
SUITE 42
Provider Business Practice Location Address City Name:
BENTONVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72712-3722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-271-9944
Provider Business Practice Location Address Fax Number:
479-271-9945
Provider Enumeration Date:
03/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BURRIS
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-443-1705

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3339 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 3460 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 4013 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 3465 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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