Basic Information
| Provider Information | |||||||||
| NPI: | 1003087362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEETRUM | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720062129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703473300 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 623 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720062129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703473300 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2008 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2307 | AR | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 167415608 | 05 | AR | MEDICAID |