Provider Demographics
NPI:1235790593
Name:BRYAN BLACKSHARE DDS
Entity Type:Organization
Organization Name:BRYAN BLACKSHARE DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMMY
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:BLACKSHARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-595-3463
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:RECTOR
Mailing Address - State:AR
Mailing Address - Zip Code:72461-0363
Mailing Address - Country:US
Mailing Address - Phone:870-595-3463
Mailing Address - Fax:
Practice Address - Street 1:737 E 9TH ST
Practice Address - Street 2:
Practice Address - City:RECTOR
Practice Address - State:AR
Practice Address - Zip Code:72461-2705
Practice Address - Country:US
Practice Address - Phone:870-595-3463
Practice Address - Fax:870-595-3208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty