Provider Demographics
NPI:1386751212
Name:SMITH, CRAIG R (DDS)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:R
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 1:2803 N BOGUS BASIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0913
Mailing Address - Country:US
Mailing Address - Phone:208-343-1393
Mailing Address - Fax:208-388-8462
Practice Address - Street 1:2803 N BOGUS BASIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-0913
Practice Address - Country:US
Practice Address - Phone:208-343-1393
Practice Address - Fax:208-388-8462
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-2077122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1386751212Medicaid
ID20-2491722OtherTIN