Provider Demographics
NPI:1427372671
Name:SMITH, MARK G (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
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 1:12001 MARKET ST APT 201
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-6213
Mailing Address - Country:US
Mailing Address - Phone:703-965-4188
Mailing Address - Fax:
Practice Address - Street 1:2349 CHERRY RD STE 49
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2132
Practice Address - Country:US
Practice Address - Phone:803-590-3054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010064381223G0001X
SC109781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice