Healthcare Provider Details

I. General information

NPI: 1497138549
Provider Name (Legal Business Name): RAJ BRAHMBHATT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 N SHILOH DR SUITE 3
FAYETTEVILLE AR
72703-5359
US

IV. Provider business mailing address

4375 N VANTAGE DR SUITE 202
FAYETTEVILLE AR
72703-4982
US

V. Phone/Fax

Practice location:
  • Phone: 479-445-6335
  • Fax: 479-301-2878
Mailing address:
  • Phone: 479-445-6335
  • Fax: 479-301-2878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4063
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: