MEDICARE: BETHEL BURRIS OLIVER PLLC

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	1223G0001X	General Practice Dentistry	3339	AR
2	1223P0221X	Pediatric Dentistry	3460	AR
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	4013	AR
4	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	3465	AR

General Provider Information

NPI Number	:	1932442803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETHEL BURRIS OLIVER PLLC

Provider Business Mailing Address
First Line	:	3782 N FRONT ST
Second Line	:	SUITE 1
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-5128
Country	:	US
Telephone Number	:	479-443-1705
Fax Number	:	479-443-1586

Provider Business Practice Location Address
First Line	:	3105 HIGHWAY 412 E
Second Line	:
City	:	SILOAM SPRINGS
State	:	AR
Zip	:	72761-8635
Country	:	US
Telephone Number	:	479-238-1004
Fax Number	:	479-238-1009

Authorized Official
Title or Position	:	OWNER
Name	:	BENJAMIN BURRIS
Credential	:	DDS, MDS, PA
Telephone Number	:	479-443-1705

Provider Enumeration Date	:	03/29/2013
Last Update Date	:	03/03/2015

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