Healthcare Provider Details

I. General information

NPI: 1245644277
Provider Name (Legal Business Name): BETHEL BURRIS OLIVER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S AVALON ST
WEST MEMPHIS AR
72301-4172
US

IV. Provider business mailing address

3782 N FRONT ST SUITE 1
FAYETTEVILLE AR
72703-5128
US

V. Phone/Fax

Practice location:
  • Phone: 870-732-2275
  • Fax: 870-732-1350
Mailing address:
  • Phone: 479-443-1705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3339
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3460
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4013
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3465
License Number StateAR

VIII. Authorized Official

Name: BENJAMIN BURRIS
Title or Position: D.D.S, M.D.S., P.A.
Credential:
Phone: 479-443-1705