Healthcare Provider Details

I. General information

NPI: 1891744462
Provider Name (Legal Business Name): ORAL & FACIAL SURGERY CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3996 N FRONTAGE RD
FAYETTEVILLE AR
72703-5122
US

IV. Provider business mailing address

PO BOX 4185
FAYETTEVILLE AR
72702-4185
US

V. Phone/Fax

Practice location:
  • Phone: 479-582-3002
  • Fax: 479-582-2840
Mailing address:
  • Phone: 479-717-1171
  • Fax: 479-927-3085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTTY L BOLDING
Title or Position: OWNER
Credential: DDS, MS
Phone: 479-957-4611