MEDICARE: RIVER DENTAL SILOAM SPRINGS, 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	122300000X	Dentist
2	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1942807144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER DENTAL SILOAM SPRINGS, PLLC

Provider Business Mailing Address
First Line	:	400 RIVERWALK TER STE 250
Second Line	:
City	:	JENKS
State	:	OK
Zip	:	74037-5619
Country	:	US
Telephone Number	:	918-998-0996
Fax Number	:

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	:	479-250-0949
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CREED CARDON
Credential	:
Telephone Number	:	918-998-0996

Provider Enumeration Date	:	10/01/2020
Last Update Date	:	10/01/2020

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