Healthcare Provider Details

I. General information

NPI: 1861665515
Provider Name (Legal Business Name): JUSTIN BETHEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 HIGHWAY 5 NORTH
BENTON AR
72019
US

IV. Provider business mailing address

407 HIGHWAY 5 NORTH
BENTON AR
72019
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-3145
  • Fax: 501-794-2033
Mailing address:
  • Phone: 501-315-3145
  • Fax: 501-794-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3339
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: