Provider Demographics
NPI:1407965106
Name:CENTRAL ARKANSAS ORAL & MAXILLOFACIAL SURGERY PA
Entity type:Organization
Organization Name:CENTRAL ARKANSAS ORAL & MAXILLOFACIAL SURGERY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:H
Authorized Official - Last Name:BYRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-268-7000
Mailing Address - Street 1:408 WEST VINE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143
Mailing Address - Country:US
Mailing Address - Phone:501-268-7000
Mailing Address - Fax:501-279-3606
Practice Address - Street 1:408 W VINE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4141
Practice Address - Country:US
Practice Address - Phone:501-268-7000
Practice Address - Fax:501-279-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARLICENSE 3108 SPEC 54204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128014679Medicaid
AR59967Medicare PIN