Provider Demographics
NPI:1891844312
Name:SMITH, JEREMY JAMES (DDS)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAMES
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 1:4310 MEDICAL PARKWAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756
Mailing Address - Country:US
Mailing Address - Phone:512-459-3129
Mailing Address - Fax:512-459-3431
Practice Address - Street 1:4310 MEDICAL PARKWAY
Practice Address - Street 2:SUITE 203
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756
Practice Address - Country:US
Practice Address - Phone:512-459-3129
Practice Address - Fax:512-459-3431
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141261223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics