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General NPI Number Information
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NPI Number | 1740449339
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Entity Type | Organization
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Legal Business Name | ARKANSAS ORTHODONTIC CENTER
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Dates
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Enumeration Date | 06/09/2008
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Last Update Date | 08/19/2008
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Provider Practice Location Address
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Address Line | 3409 GATEWAY COVE
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City | JONESBORO
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State | AR
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Zip | 72404
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Country | US
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Telephone | 870-972-0460
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Fax |
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Provider Business Mailing Address
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Address Line | 3409 GATEWAY COVE
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City | JONESBORO
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State | AR
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Zip | 72404
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Country | US
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Telephone | 870-972-0460
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. BENJAMIN GRAY BURRIS
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Credential | DDS MDS PA
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Telephone | 870-972-8249
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 3465
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License Number State | AR
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