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General NPI Number Information
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NPI Number | 1255634291
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Entity Type | Organization
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Legal Business Name | BURRIS-DAKE ORAL SURGERY
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Dates
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Enumeration Date | 12/14/2010
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Last Update Date | 12/14/2010
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Provider Practice Location Address
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Address Line | 2801 S OLIVE ST SUITE 33B
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City | PINE BLUFF
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State | AR
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Zip | 71603-5433
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Country | US
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Telephone | 870-534-2131
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Fax | 870-534-2175
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Provider Business Mailing Address
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Address Line | 2801 S OLIVE ST SUITE 33B
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City | PINE BLUFF
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State | AR
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Zip | 71603-5433
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Country | US
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Telephone | 870-534-2131
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Fax | 870-534-2175
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Authorized Official
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Title or Position | SOLE MANAGER
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Name | DR. BENJAMIN G BURRIS
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Credential | DDS
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Telephone | 870-534-2131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 3802
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License Number State | AR
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