Provider Demographics
NPI:1063922649
Name:SMART DENTAL
Entity type:Organization
Organization Name:SMART DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-535-5155
Mailing Address - Street 1:425 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-9103
Mailing Address - Country:US
Mailing Address - Phone:816-535-5155
Mailing Address - Fax:
Practice Address - Street 1:425 W PINE ST
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-9103
Practice Address - Country:US
Practice Address - Phone:816-535-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO011945261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental