Healthcare Provider Details

I. General information

NPI: 1790063923
Provider Name (Legal Business Name): BETHEL BURRIS OLIVER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 BROWNS LANE
JONESBORO AR
72401
US

IV. Provider business mailing address

3787 N. FRONT ST. SUITE 1
FAYETTEVILLE AR
72703-5906
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 TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3465
License Number StateAR
# 5
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateAR

VIII. Authorized Official

Name: DR. BENJAMIN G. BURRIS
Title or Position: OWNER
Credential: DDS, MDS, PA
Phone: 479-445-6335