| NPI | 1235790593 | The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
| Entity Type Code | 2 | Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Employer Identification Number EIN | UNAVAIL | The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
| Provider Organization Name Legal Business Name | BRYAN BLACKSHARE DDS | The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider First Line Business Mailing Address | PO BOX 363 | The first line mailing address of the provider
being identified. This data element may contain the same information as ‘‘Provider first line location address’’. |
| Provider Business Mailing Address City Name | RECTOR | The city name in the mailing address of the provider being identified. |
| Provider Business Mailing Address State Name | AR | The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’. |
| Provider Business Mailing Address Postal Code | 724610363 | The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location
address postal code’’. |
| Provider Business Mailing Address Country Code If outside U S | US | The country code in the mailing address of the provider being identified. This data element may contain the same information
as ‘‘Provider location address country
code’’. |
| Provider Business Mailing Address Telephone Number | 8705953463 | The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location
address telephone number’’. |
| Provider First Line Business Practice Location Address | 737 E 9TH ST | The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name | RECTOR | The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name | AR | The State code in the location of the provider
being identified. |
| Provider Business Practice Location Address Postal Code | 724612705 | The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S | US | The country code in the location address of the provider being identified. |
| Provider Business Practice Location Address Telephone Number | 8705953463 | The telephone number associated with the location address of the provider being identified. |
| Provider Business Practice Location Address Fax Number | 8705953208 | The fax number associated with the location
address of the provider being identified. |
| Provider Enumeration Date | 6/26/2019 | The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date | 6/26/2019 | The date that a record was last updated or changed. |
| Authorized Official Last Name | BLACKSHARE | The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Authorized Official First Name | SAMMY | The first name of the authorized official. |
| Authorized Official Middle Name | BRYAN | The middle name of the authorized official. |
| Authorized Official Title or Position | OWNER | The title or position of the authorized official. |
| Authorized Official Telephone Number | 8705953463 | The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 | 122300000X | Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 | Y | |
| Is Organization Subpart | N | |
| Authorized Official Name Prefix Text | DR. | |
| Healthcare Provider Taxonomy Group 1 | 193400000X SINGLE SPECIALTY GROUP | |
