Provider Demographics
NPI:1487727012
Name:SMITH, BRIAN A (DMD,PC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 SENOIA RD
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1622
Mailing Address - Country:US
Mailing Address - Phone:770-487-7775
Mailing Address - Fax:770-964-9660
Practice Address - Street 1:1134 SENOIA RD
Practice Address - Street 2:SUITE A-2
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1622
Practice Address - Country:US
Practice Address - Phone:770-487-7775
Practice Address - Fax:770-964-9660
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA120181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA538925OtherUNITED CONCORDIA PROVID #