Healthcare Provider Details

I. General information

NPI: 1740449339
Provider Name (Legal Business Name): ARKANSAS ORTHODONTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 GATEWAY COVE
JONESBORO AR
72404
US

IV. Provider business mailing address

3409 GATEWAY COVE
JONESBORO AR
72404
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-0460
  • Fax:
Mailing address:
  • Phone: 870-972-0460
  • Fax:

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 GRAY BURRIS
Title or Position: ORTHODONTIST
Credential: DDS MDS PA
Phone: 870-972-8249