Provider Demographics
NPI:1750433686
Name:BUNTIN, JOHN WATSON (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WATSON
Last Name:BUNTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303
Mailing Address - Country:US
Mailing Address - Phone:870-735-1673
Mailing Address - Fax:870-735-2847
Practice Address - Street 1:312 MISSOURI ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-735-1673
Practice Address - Fax:870-735-2847
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2346122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0184611OtherBLUE CROSS BLUE SHIELD
156643OtherUNITED CONCORDIA
AR58956OtherBLUE CROSS BLUE SHIELD