Provider Demographics
NPI:1588910657
Name:SMITH, KEVIN DOUGLAS (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155B GARDNER LOOP # B
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10996-1114
Mailing Address - Country:US
Mailing Address - Phone:253-576-2478
Mailing Address - Fax:
Practice Address - Street 1:900 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996-1109
Practice Address - Country:US
Practice Address - Phone:845-938-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO2504600122300000X
NY059103-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist