Provider Demographics
NPI:1205211976
Name:HIGGINBOTHAM DENTAL GROUP, PLLC
Entity Type:Organization
Organization Name:HIGGINBOTHAM DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-336-3732
Mailing Address - Street 1:1804 OLD GREENSBORO RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-0003
Mailing Address - Country:US
Mailing Address - Phone:870-336-3732
Mailing Address - Fax:870-336-3810
Practice Address - Street 1:1804 OLD GREENSBORO RD STE D
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-2076
Practice Address - Country:US
Practice Address - Phone:870-333-1352
Practice Address - Fax:870-336-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-23
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
AR3888261QD0000X
AR3561261QD0000X
AR3764261QD0000X
AR4005261QD0000X
AR3992261QD0000X
AR3393261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty