Basic Information
| Provider Information | |||||||||
| NPI: | 1417002106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRETT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LESTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 2802 HIGHWAY 367 N | ||||||||
| Address2: | |||||||||
| City: | BALD KNOB | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720103165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707246207 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 2146 (17) | AR | Y | Dental Providers | Dentist | Pediatric Dentistry | 122300000X | 2146 | AR | N | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 101731608 | 05 | AR | MEDICAID |