Provider Demographics
NPI:1669035770
Name:RIVER DENTAL ROGERS SOUTH, PLLC
Entity Type:Organization
Organization Name:RIVER DENTAL ROGERS SOUTH, PLLC
Other - Org Name:RIVER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CREED
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-998-0996
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2603 W PLEASANT GROVE RD STE 111
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8514
Practice Address - Country:US
Practice Address - Phone:479-282-1023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty