Provider Demographics
NPI:1689021420
Name:BOYETTE FACIAL PLASTIC SURGERY, PA
Entity Type:Organization
Organization Name:BOYETTE FACIAL PLASTIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNINGS
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BOYETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-205-8610
Mailing Address - Street 1:PO BOX 241212
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-0004
Mailing Address - Country:US
Mailing Address - Phone:501-205-8610
Mailing Address - Fax:501-205-8610
Practice Address - Street 1:9601 LILE DR.
Practice Address - Street 2:MEDICAL TOWERS BUILDING 1, SUITE 970B
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6321
Practice Address - Country:US
Practice Address - Phone:501-205-8610
Practice Address - Fax:501-205-8610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-78942086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty