Healthcare Provider Details

I. General information

NPI: 1780754036
Provider Name (Legal Business Name): RANDALL S HESTIR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 S WHITEHEAD DR
DEWITT AR
72042
US

IV. Provider business mailing address

1703 S WHITEHEAD DR PO DRAWER 512
DEWITT AR
72042
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-2013
  • Fax: 870-946-1281
Mailing address:
  • Phone: 870-946-2013
  • Fax: 870-946-1281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2266
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: