Provider Demographics
NPI:1376808394
Name:RIVER VALLEY DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:RIVER VALLEY DENTAL GROUP PLLC
Other - Org Name:RIVER VALLEY SMILE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIGGETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-646-0706
Mailing Address - Street 1:8309 PHOENIX AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:479-646-0706
Mailing Address - Fax:479-646-0502
Practice Address - Street 1:8309 PHOENIX AVENUE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-646-0706
Practice Address - Fax:479-646-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159196608Medicaid
AR152884608Medicaid
OK20032200AMedicaid