Provider Demographics
NPI:1578302386
Name:MAXWELL, BETHANY DEANN
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:DEANN
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16192 N HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-8576
Mailing Address - Country:US
Mailing Address - Phone:479-228-2312
Mailing Address - Fax:
Practice Address - Street 1:301 S J T STITES ST
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9302
Practice Address - Country:US
Practice Address - Phone:918-775-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist