MEDICARE: RIVER VALLEY ORAL & MAXILLOFACIAL SURGERY PLC

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2226	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000516007	OTHER		UNITED CONCORDIA (IND-JR)
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	58111	OTHER	AR	BLUE CROSS BLUE SHIELD
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	000861460	OTHER		UNITED CONCORDIA (GRP)
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	1871553958	OTHER		INDIVIDUAL NPI
8	58041	OTHER	AR	BLUE CROSS BLUE SHIELD
9	000812852	OTHER		UNITED CONCORDIA (IND-JB)
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	1629038708	OTHER		INDIVIDUAL NPI

General Provider Information

NPI Number	:	1548288244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER VALLEY ORAL & MAXILLOFACIAL SURGERY PLC

Provider Business Mailing Address
First Line	:	2407 S WALDRON RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3736
Country	:	US
Telephone Number	:	479-484-1011
Fax Number	:	479-484-1205

Provider Business Practice Location Address
First Line	:	2407 S WALDRON RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3736
Country	:	US
Telephone Number	:	479-484-1011
Fax Number	:	479-484-1205

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. GAYLE M. FREEMAN
Credential	:
Telephone Number	:	479-484-1011

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	04/27/2009

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