Provider Demographics
NPI:1285764860
Name:SMITH, MICHAEL R (DMD,PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3671 SAINT ANDREWS CT
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-8051
Mailing Address - Country:US
Mailing Address - Phone:904-637-0028
Mailing Address - Fax:904-215-9887
Practice Address - Street 1:1530 BUSINESS CENTER DR
Practice Address - Street 2:SUITE #1
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-9026
Practice Address - Country:US
Practice Address - Phone:904-637-0028
Practice Address - Fax:904-215-9887
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN137881223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics