Healthcare Provider Details

I. General information

NPI: 1154793982
Provider Name (Legal Business Name): WHITE & BLANSETT PERIODONTICS & DENTAL IMPLANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N 34TH ST
ROGERS AR
72756-0352
US

IV. Provider business mailing address

201 N 34TH ST
ROGERS AR
72756-0352
US

V. Phone/Fax

Practice location:
  • Phone: 479-631-6074
  • Fax: 479-936-8660
Mailing address:
  • Phone: 479-631-6074
  • Fax: 479-936-8660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3958
License Number StateAR

VIII. Authorized Official

Name: DR. JONATHAN ANDREW BLANSETT
Title or Position: PERIODONTIST
Credential: DDS, PLLC
Phone: 479-631-6074