Provider Demographics
NPI:1194770362
Name:SMITH, KEITH WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WAYNE
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 1:2501 MARKET TRCE
Mailing Address - Street 2:STE A
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8677
Mailing Address - Country:US
Mailing Address - Phone:479-434-6966
Mailing Address - Fax:
Practice Address - Street 1:2501 MARKET TRCE
Practice Address - Street 2:STE A
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8677
Practice Address - Country:US
Practice Address - Phone:479-434-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR995157OtherCOMPBENEFITS FACILITY #
AR975050OtherUNITED CONCORDIA PROV. #
AR5T895OtherBCBS PROVIDER #