Provider Demographics
NPI:1952587107
Name:NORTHWEST ARKANSAS ORAL & MAXILLOFACIAL SURGERY PLLC
Entity Type:Organization
Organization Name:NORTHWEST ARKANSAS ORAL & MAXILLOFACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-966-4004
Mailing Address - Street 1:163 W VAN ASCHE LOOP
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4974
Mailing Address - Country:US
Mailing Address - Phone:479-966-4004
Mailing Address - Fax:479-935-4004
Practice Address - Street 1:163 W VAN ASCHE LOOP
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4974
Practice Address - Country:US
Practice Address - Phone:479-966-4004
Practice Address - Fax:479-935-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34911223S0112X
AR15711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty