Provider Demographics
NPI:1306063391
Name:ROBERT C. GOLDTRAP,DDS,INC
Entity type:Organization
Organization Name:ROBERT C. GOLDTRAP,DDS,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOLDTRAP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-484-7645
Mailing Address - Street 1:8309 PHOENIX AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-0001
Mailing Address - Country:US
Mailing Address - Phone:479-484-7645
Mailing Address - Fax:479-484-1551
Practice Address - Street 1:8309 PHOENIX AVENUE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-0001
Practice Address - Country:US
Practice Address - Phone:479-484-7645
Practice Address - Fax:479-484-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR464681OtherUNITED CONCORDIA
AR5U751OtherBLUE CROSS BLUE SHIELD
AR160840631Medicaid
AR5U751OtherBLUE CROSS BLUE SHIELD