Healthcare Provider Details

I. General information

NPI: 1962598433
Provider Name (Legal Business Name): SAM R. SHANLEVER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 W STATE HIGHWAY 22
RATCLIFF AR
72951-9000
US

IV. Provider business mailing address

PO BOX 130
RATCLIFF AR
72951-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-635-5300
  • Fax: 479-635-2010
Mailing address:
  • Phone: 479-635-5300
  • Fax: 479-635-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2285
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: