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Oral and Maxillofacial Surgery

Fayetteville, Arkansas

Provider NPI: 1376691097

Provider Information:
Gender: M
Not Sole Proprietor

Practice Location:
Tel: 479-582-3002  Fax: 479-582-2840

Business Mailing Address:
Tel: 479-717-1171  Fax: 479-725-2395

Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Y1223S0112XDental Providers
Oral and Maxillofacial Surgery
Oral & Maxillofacial Surgery

Other Provider Identifiers:

Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin


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