Provider Demographics
NPI:1194869446
Name:DONAVAN SMITH, DDS A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:DONAVAN SMITH, DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONAVAN
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-593-0300
Mailing Address - Street 1:2149 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:LA
Mailing Address - Zip Code:70583-5301
Mailing Address - Country:US
Mailing Address - Phone:337-593-0300
Mailing Address - Fax:
Practice Address - Street 1:2149 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583-5301
Practice Address - Country:US
Practice Address - Phone:337-593-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4814122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty