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General NPI Number Information
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NPI Number | 1669035770
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Entity Type | Organization
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Legal Business Name | RIVER DENTAL ROGERS SOUTH, PLLC
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Dates
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Enumeration Date | 04/16/2019
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Last Update Date | 02/18/2020
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Provider Practice Location Address
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Address Line | 2603 W PLEASANT GROVE RD STE 111
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City | ROGERS
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State | AR
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Zip | 72758-8514
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Country | US
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Telephone | 479-282-1023
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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 |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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