MEDICARE: RIVER DENTAL VAN BUREN PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1194398552
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER DENTAL VAN BUREN PLLC

Provider Business Mailing Address
First Line	:	400 RIVERWALK TER STE 250
Second Line	:
City	:	JENKS
State	:	OK
Zip	:	74037-5619
Country	:	US
Telephone Number	:	918-998-0996
Fax Number	:	918-310-1056

Provider Business Practice Location Address
First Line	:	2025 FAYETTEVILLE RD STE B
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-6981
Country	:	US
Telephone Number	:	918-998-0996
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	SARA BROWN
Credential	:
Telephone Number	:	918-998-0996

Provider Enumeration Date	:	07/22/2021
Last Update Date	:	07/22/2021

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