Healthcare Provider Details

I. General information

NPI: 1083957351
Provider Name (Legal Business Name): GATEWAY VENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3782 N FRONT ST SUITE 1
FAYETTEVILLE AR
72703-5128
US

IV. Provider business mailing address

3782 N FRONT ST SUITE 1
FAYETTEVILLE AR
72703-5128
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-1705
  • Fax: 479-443-1586
Mailing address:
  • Phone: 479-443-1705
  • Fax: 479-443-1586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateAR

VIII. Authorized Official

Name: BENJAMIN BURRIS
Title or Position: OWNER
Credential: D.D.S., M.D.S.
Phone: 479-443-1705