Provider Demographics
NPI:1851634729
Name:BETHEL BURRIS OLIVER PLLC
Entity Type:Organization
Organization Name:BETHEL BURRIS OLIVER PLLC
Other - Org Name:ARKANSAS DENTISTRY AND BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MDS, PA
Authorized Official - Phone:479-782-7080
Mailing Address - Street 1:4375 N VANTAGE DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5128
Mailing Address - Country:US
Mailing Address - Phone:479-445-6335
Mailing Address - Fax:479-301-2878
Practice Address - Street 1:4605 S PHOENIX AVENUE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-1713
Practice Address - Country:US
Practice Address - Phone:479-782-7080
Practice Address - Fax:479-782-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33391223G0001X
AR34601223P0221X
AR40131223S0112X
AR34651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty