Provider Demographics
NPI:1487855417
Name:DR HEATHER BOND SOUTHARD, DDS PA
Entity Type:Organization
Organization Name:DR HEATHER BOND SOUTHARD, DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:BOND
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-932-7000
Mailing Address - Street 1:2600 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7226
Mailing Address - Country:US
Mailing Address - Phone:870-932-7000
Mailing Address - Fax:870-932-1650
Practice Address - Street 1:2600 BROWNS LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7226
Practice Address - Country:US
Practice Address - Phone:870-932-7000
Practice Address - Fax:870-932-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161820608Medicaid