Provider Demographics
NPI:1871104190
Name:DR. BRADLEY JORDAN SLAUGHTER
Entity type:Organization
Organization Name:DR. BRADLEY JORDAN SLAUGHTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:SLAUGHTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-793-7520
Mailing Address - Street 1:3401 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-8820
Mailing Address - Country:US
Mailing Address - Phone:870-793-7520
Mailing Address - Fax:870-793-2662
Practice Address - Street 1:3401 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-8820
Practice Address - Country:US
Practice Address - Phone:870-793-7520
Practice Address - Fax:870-793-2662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186342608Medicaid