MEDICARE: BENJAMIN G. BURRIS, DDS, MDS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	3465	AR

General Provider Information

NPI Number	:	1386085801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENJAMIN G. BURRIS, DDS, MDS, PA

Provider Business Mailing Address
First Line	:	1126 S ROGERS ST
Second Line	:
City	:	CLARKSVILLE
State	:	AR
Zip	:	72830-9157
Country	:	US
Telephone Number	:	479-754-6084
Fax Number	:

Provider Business Practice Location Address
First Line	:	1126 S ROGERS ST
Second Line	:
City	:	CLARKSVILLE
State	:	AR
Zip	:	72830-9157
Country	:	US
Telephone Number	:	479-754-6084
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BENJAMIN BURRIS
Credential	:	DDS, MDS
Telephone Number	:	870-972-8294

Provider Enumeration Date	:	07/12/2013
Last Update Date	:	07/12/2013

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