Provider Demographics
NPI:1285622936
Name:SMITH, DARRELL
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 41 BOX 5589
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09464
Mailing Address - Country:GB
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 41 BOX 5589
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09464
Practice Address - Country:GB
Practice Address - Phone:0163-852-8800
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist