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General NPI Number Information
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NPI Number | 1407512825
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Entity Type | Organization
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Legal Business Name | RIVER DENTAL BELLA VISTA PLLC
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Dates
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Enumeration Date | 11/10/2021
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Last Update Date | 11/08/2023
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Provider Practice Location Address
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Address Line | 3489 BELLA VISTA WAY
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City | BELLA VISTA
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State | AR
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Zip | 72714-5740
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Country | US
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Telephone | 918-998-0996
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Fax |
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Provider Business Mailing Address
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Address Line | 400 RIVERWALK TER STE 250
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City | JENKS
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State | OK
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Zip | 74037-5619
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Country | US
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Telephone | 918-998-0996
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CREED CARDON
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Credential |
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Telephone | 918-998-0996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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