Provider Demographics
NPI:1114076759
Name:JIRIK, SAMUEL F (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:F
Last Name:JIRIK
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 W MAIN ST
Mailing Address - Street 2:P.O. BOX 1115
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-2423
Mailing Address - Country:US
Mailing Address - Phone:501-843-9561
Mailing Address - Fax:501-843-5971
Practice Address - Street 1:606 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-2423
Practice Address - Country:US
Practice Address - Phone:501-843-9561
Practice Address - Fax:501-843-5971
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2741122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR2741OtherSTATE LICENSE
AR59168OtherBCBS PROVIDER
AR625384OtherUNITED CONCORDIA PROVIDER