Provider Demographics
NPI:1073886156
Name:JEFFERSON COMPREHENSIVE CARE SYSTEM, INC.
Entity Type:Organization
Organization Name:JEFFERSON COMPREHENSIVE CARE SYSTEM, INC.
Other - Org Name:COLLEGE STATION DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARNELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-543-2380
Mailing Address - Street 1:PO BOX 1285
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-1285
Mailing Address - Country:US
Mailing Address - Phone:870-536-5581
Mailing Address - Fax:870-536-3565
Practice Address - Street 1:4206 FRAZIER PIKE
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:AR
Practice Address - Zip Code:72053-0668
Practice Address - Country:US
Practice Address - Phone:501-490-2440
Practice Address - Fax:501-490-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56811OtherBLUE CROSS BLUE SHIELD