Provider Demographics
NPI:1699910034
Name:TODD HIGGINBOTHAM, PA
Entity type:Organization
Organization Name:TODD HIGGINBOTHAM, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:UGLEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-539-6621
Mailing Address - Street 1:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:LEACHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72438-0109
Mailing Address - Country:US
Mailing Address - Phone:870-539-6621
Mailing Address - Fax:870-539-6334
Practice Address - Street 1:126 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEACHVILLE
Practice Address - State:AR
Practice Address - Zip Code:72438
Practice Address - Country:US
Practice Address - Phone:870-539-6621
Practice Address - Fax:870-539-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F953OtherBLUE CROSS BLUE SHIELD GROUP ID NUMBER