Provider Demographics
NPI:1063441384
Name:SMITH, GARY ALFRED (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALFRED
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3510
Mailing Address - Country:US
Mailing Address - Phone:712-323-3615
Mailing Address - Fax:712-325-6155
Practice Address - Street 1:2612 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3510
Practice Address - Country:US
Practice Address - Phone:712-323-3615
Practice Address - Fax:712-325-6155
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA66991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA039537OtherUNITED CONCORDIA
IA18575OtherDELTA DENTAL-IA
NE5334OtherBLUE CROSS/BLUE SHIELD-NE
IA18575OtherWELLMARK