Provider Demographics
NPI:1154554921
Name:SMITH, GREGORY ROBERTS (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ROBERTS
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 1:1375 FARNHAM PT APT 207
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-5211
Mailing Address - Country:US
Mailing Address - Phone:443-600-2187
Mailing Address - Fax:
Practice Address - Street 1:3236 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4077
Practice Address - Country:US
Practice Address - Phone:443-600-2187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5498321-99211223G0001X
UT5498321-89031223G0001X
CO100831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice