Provider Demographics
NPI:1336482264
Name:BETHEL BURRIS OLIVER PLLC
Entity Type:Organization
Organization Name:BETHEL BURRIS OLIVER PLLC
Other - Org Name:ARKANSAS DENTISTRY AND BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MDS
Authorized Official - Phone:479-442-3411
Mailing Address - Street 1:3782 N FRONT ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5128
Mailing Address - Country:US
Mailing Address - Phone:479-443-1705
Mailing Address - Fax:479-443-1586
Practice Address - Street 1:3533 N SHILOH DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5359
Practice Address - Country:US
Practice Address - Phone:479-442-3411
Practice Address - Fax:479-442-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33391223G0001X
AR34601223P0221X
AR40131223S0112X
AR34651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty