Provider Demographics
NPI:1487717880
Name:SMITH, ROBERT LEWIS JR (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEWIS
Last Name:SMITH
Suffix:JR
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 1:007 E COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-2215
Mailing Address - Country:US
Mailing Address - Phone:662-429-5055
Mailing Address - Fax:662-429-5056
Practice Address - Street 1:007 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2215
Practice Address - Country:US
Practice Address - Phone:662-429-5055
Practice Address - Fax:662-429-5056
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1947811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064895Medicaid