Organization
JEFFERSON COMPREHENSIVE CARE SYSTEM, INC.
Active
Other names
College Station Dental
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LARNELL W. DAVIS (EXECUTIVE DIRECTOR)
(870) 543-2380
Entity
Organization
Contact information
Practice address
4206 FRAZIER PIKE, COLLEGE STATION, AR 72053-0668
(501) 490-2440
(501) 490-0156
Mailing address
PO BOX 1285, PINE BLUFF, AR 71613-1285
(870) 536-5581
(870) 536-3565
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
56811
BLUE CROSS BLUE SHIELD
AR
Enumeration date
02/20/2012
Last updated
02/20/2012
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