Basic Information
| Provider Information | |||||||||
| NPI: | 1962598433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANLEVER | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | RATCLIFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729510130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796355300 | ||||||||
| FaxNumber: | 4796352010 | ||||||||
| Practice Location | |||||||||
| Address1: | 9755 W STATE HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | RATCLIFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729519000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796355300 | ||||||||
| FaxNumber: | 4796352010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 03/02/2010 | ||||||||
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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 | 2285 | AR | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 103823608 | 05 | AR | MEDICAID | 846647 | 01 | AR | UNITED CONCORDIA | OTHER | 58898 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER |