Provider Demographics
NPI:1124263579
Name:HIGGINBOTHAM DENTAL GROUP, PLLC
Entity type:Organization
Organization Name:HIGGINBOTHAM DENTAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-336-3732
Mailing Address - Street 1:1804 OLD GREENSBORO RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-0003
Mailing Address - Country:US
Mailing Address - Phone:870-336-3732
Mailing Address - Fax:
Practice Address - Street 1:321 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5854
Practice Address - Country:US
Practice Address - Phone:870-932-8585
Practice Address - Fax:870-932-0949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33931223G0001X, 1223G0001X
AR36401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F953OtherBLUE CROSS BLUE SHIELD GROUP ID NUMBER