Healthcare Provider Details

I. General information

NPI: 1730435967
Provider Name (Legal Business Name): BILLY C CRISWELL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 FAYETTEVILLE RD STE. C
VAN BUREN AR
72956-6520
US

IV. Provider business mailing address

2411 FAYETTEVILLE RD STE. C
VAN BUREN AR
72956-6520
US

V. Phone/Fax

Practice location:
  • Phone: 479-474-2828
  • Fax: 479-262-6884
Mailing address:
  • Phone: 479-474-2828
  • Fax: 479-262-6884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. BYRL C CRISWELL
Title or Position: PRESIDENT
Credential: DDS
Phone: 479-474-2828