Provider Demographics
NPI:1487095139
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:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MDS
Authorized Official - Phone:870-972-8294
Mailing Address - Street 1:126 W BOND AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-3909
Mailing Address - Country:US
Mailing Address - Phone:870-972-8294
Mailing Address - Fax:870-735-7853
Practice Address - Street 1:4375 N VANTAGE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4982
Practice Address - Country:US
Practice Address - Phone:870-972-8294
Practice Address - Fax:870-735-7853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190787631Medicaid