Provider Demographics
NPI:1023183050
Name:BLACKSHARE, SAMMY BRYAN (DDS)
Entity Type:Individual
Prefix:
First Name:SAMMY
Middle Name:BRYAN
Last Name:BLACKSHARE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:737 E 9TH
Mailing Address - City:RECTOR
Mailing Address - State:AR
Mailing Address - Zip Code:72461
Mailing Address - Country:US
Mailing Address - Phone:870-595-3463
Mailing Address - Fax:870-595-3208
Practice Address - Street 1:737 E 9TH
Practice Address - Street 2:
Practice Address - City:RECTOR
Practice Address - State:AR
Practice Address - Zip Code:72461
Practice Address - Country:US
Practice Address - Phone:870-595-3463
Practice Address - Fax:870-595-3208
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2730122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR59281OtherBC BS
AR840563OtherUNITED CONCORDIA
TN3014523OtherBC BS