Provider Demographics
NPI:1548288244
Name:RIVER VALLEY ORAL & MAXILLOFACIAL SURGERY PLC
Entity type:Organization
Organization Name:RIVER VALLEY ORAL & MAXILLOFACIAL SURGERY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-484-1011
Mailing Address - Street 1:2407 S WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3736
Mailing Address - Country:US
Mailing Address - Phone:479-484-1011
Mailing Address - Fax:479-484-1205
Practice Address - Street 1:2407 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3736
Practice Address - Country:US
Practice Address - Phone:479-484-1011
Practice Address - Fax:479-484-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000516007OtherUNITED CONCORDIA (IND-JR)
AR127322679Medicaid
AR58111OtherBLUE CROSS BLUE SHIELD
OK100026580AMedicaid
000861460OtherUNITED CONCORDIA (GRP)
OK100174630AMedicaid
1871553958OtherINDIVIDUAL NPI
AR58041OtherBLUE CROSS BLUE SHIELD
000812852OtherUNITED CONCORDIA (IND-JB)
AR127321679Medicaid
1629038708OtherINDIVIDUAL NPI
000861460OtherUNITED CONCORDIA (GRP)
OK100174630AMedicaid
58041Medicare PIN
000516007OtherUNITED CONCORDIA (IND-JR)
AR58111OtherBLUE CROSS BLUE SHIELD