Healthcare Provider Details

I. General information

NPI: 1629981790
Provider Name (Legal Business Name): SB DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 N COLLEGE AVE RM 201
FAYETTEVILLE AR
72701-4203
US

IV. Provider business mailing address

PO BOX 8431
FAYETTEVILLE AR
72703-0008
US

V. Phone/Fax

Practice location:
  • Phone: 479-287-9978
  • Fax:
Mailing address:
  • Phone: 479-287-9978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JOSEPH BLACKMON
Title or Position: MEMBER
Credential: MD
Phone: 479-287-9978