Provider Demographics
NPI:1366578536
Name:SMITH, GREGORY ROSS (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ROSS
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 1:600 OAK ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3246
Mailing Address - Country:US
Mailing Address - Phone:916-786-9066
Mailing Address - Fax:916-786-9074
Practice Address - Street 1:600 OAK ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-3246
Practice Address - Country:US
Practice Address - Phone:916-786-9066
Practice Address - Fax:916-786-9074
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice