Healthcare Provider Details

I. General information

NPI: 1487095139
Provider Name (Legal Business Name): BETHEL BURRIS OLIVER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

126 W BOND AVE
WEST MEMPHIS AR
72301-3909
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-8294
  • Fax: 870-735-7853
Mailing address:
  • Phone: 870-972-8294
  • Fax: 870-735-7853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3465
License Number StateAR

VIII. Authorized Official

Name: DR. BENJAMIN G BURRIS
Title or Position: OWNER
Credential: DDS, MDS
Phone: 870-972-8294