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General NPI Number Information
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NPI Number | 1770848681
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Entity Type | Organization
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Legal Business Name | HIGGINBOTHAM DENTAL GROUP, PLLC
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Dates
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Enumeration Date | 07/06/2012
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Last Update Date | 10/14/2020
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Provider Practice Location Address
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Address Line | 255 W BROADWAY ST
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City | WEST MEMPHIS
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State | AR
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Zip | 72301-3903
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Country | US
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Telephone | 870-225-2500
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Fax |
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Provider Business Mailing Address
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Address Line | 1804 OLD GREENSBORO RD BLDG B
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City | JONESBORO
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State | AR
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Zip | 72405-0003
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Country | US
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Telephone | 870-336-3732
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Fax |
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Authorized Official
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Title or Position | INS DIRECTOR
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Name | MISTI ROSS
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Credential |
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Telephone | 870-336-3732
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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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