Healthcare Provider Details

I. General information

NPI: 1336880913
Provider Name (Legal Business Name): BRANDON SCOTT BULLOCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3394 N FUTRALL DR STE 2
FAYETTEVILLE AR
72703-3937
US

IV. Provider business mailing address

3394 N FUTRALL DR STE 2
FAYETTEVILLE AR
72703-3937
US

V. Phone/Fax

Practice location:
  • Phone: 479-582-3360
  • Fax:
Mailing address:
  • Phone: 479-582-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4795
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number28
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: