Healthcare Provider Details

I. General information

NPI: 1376821181
Provider Name (Legal Business Name): JONATHAN ANDREW BLANSETT DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2522 S PINNACLE HILLS PKWY STE 102
ROGERS AR
72758-1415
US

IV. Provider business mailing address

2522 S PINNACLE HILLS PKWY STE 102
ROGERS AR
72758-1415
US

V. Phone/Fax

Practice location:
  • Phone: 479-282-2812
  • Fax: 479-936-8660
Mailing address:
  • Phone: 479-282-2812
  • Fax: 479-340-0068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number27107
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3958
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3958(DDS); 37(PERIO)
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: