Provider Demographics
NPI:1114292984
Name:BEAU SPARKMAN D.D.S., P.A.
Entity Type:Organization
Organization Name:BEAU SPARKMAN D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-739-4999
Mailing Address - Street 1:104 W RAY FINE BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-5289
Mailing Address - Country:US
Mailing Address - Phone:918-503-6262
Mailing Address - Fax:
Practice Address - Street 1:104 W RAY FINE BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5289
Practice Address - Country:US
Practice Address - Phone:918-503-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK63471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200343870AMedicaid