Healthcare Provider Details

I. General information

NPI: 1003092545
Provider Name (Legal Business Name): ARKLATEX ORAL & MAXILLOFACIAL SURGERY A PARTNERSHIP OF PROFESSIONAL DE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 FERN AVE BUILDING 1400
SHREVEPORT LA
71105-5659
US

IV. Provider business mailing address

7600 FERN AVE BUILDING 1400
SHREVEPORT LA
71105-5659
US

V. Phone/Fax

Practice location:
  • Phone: 318-797-5812
  • Fax:
Mailing address:
  • Phone: 318-797-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRIAN R SMITH
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 318-797-5812