Provider Demographics
NPI:1124173356
Name:SMITH, DENNIS RAYVON (DDS)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:RAYVON
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:PO BOX 326
Mailing Address - Street 2:106 COLLEGE STREET
Mailing Address - City:GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:31031-0326
Mailing Address - Country:US
Mailing Address - Phone:478-628-2142
Mailing Address - Fax:478-628-1400
Practice Address - Street 1:106 COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:GA
Practice Address - Zip Code:31031-0326
Practice Address - Country:US
Practice Address - Phone:478-628-2142
Practice Address - Fax:478-628-1400
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100138OtherAVESIS
GA000018378CMedicaid
GA108516OtherDORAL - WELLCARE
GA582423363OtherTAX ID #