Provider Demographics
NPI:1417268426
Name:B.W. PETKOVICH, D.D.S., PA
Entity Type:Organization
Organization Name:B.W. PETKOVICH, D.D.S., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PETKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-425-9757
Mailing Address - Street 1:500 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2913
Mailing Address - Country:US
Mailing Address - Phone:870-425-9757
Mailing Address - Fax:
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2913
Practice Address - Country:US
Practice Address - Phone:870-425-9757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR23711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty