Provider Demographics
NPI:1760809537
Name:JIM BLANCHARD DDS PA
Entity Type:Organization
Organization Name:JIM BLANCHARD DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-423-6963
Mailing Address - Street 1:201 RICE ST
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-4388
Mailing Address - Country:US
Mailing Address - Phone:870-423-6963
Mailing Address - Fax:870-423-2109
Practice Address - Street 1:201 RICE ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4388
Practice Address - Country:US
Practice Address - Phone:870-423-6963
Practice Address - Fax:870-423-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2381261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104808608Medicaid