Healthcare Provider Details

I. General information

NPI: 1578661914
Provider Name (Legal Business Name): BETHEL BURRIS OLIVER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 HIGHWAY 5 N
BENTON AR
72019-9778
US

IV. Provider business mailing address

3782 N FRONT ST STE 1
FAYETTEVILLE AR
72703-5906
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-3145
  • Fax: 501-794-2033
Mailing address:
  • Phone: 479-445-6335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN G BURRIS
Title or Position: OWNER
Credential: DDS, MDS, PA
Phone: 479-445-6335