Provider Demographics
NPI:1245644277
Name:BETHEL BURRIS OLIVER PLLC
Entity type:Organization
Organization Name:BETHEL BURRIS OLIVER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:D.D.S, M.D.S., P.A.
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-443-1705
Mailing Address - Street 1:3782 N FRONT ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5128
Mailing Address - Country:US
Mailing Address - Phone:479-443-1705
Mailing Address - Fax:
Practice Address - Street 1:203 S AVALON ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4172
Practice Address - Country:US
Practice Address - Phone:870-732-2275
Practice Address - Fax:870-732-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34601223P0221X
AR40131223S0112X
AR34651223X0400X
AR33391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty