Provider Demographics
NPI:1962541953
Name:SMITH, MARK R (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
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 1:1819 61ST AVE.
Mailing Address - Street 2:#102
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634
Mailing Address - Country:US
Mailing Address - Phone:970-356-7474
Mailing Address - Fax:970-356-2474
Practice Address - Street 1:1819 61ST AVE.
Practice Address - Street 2:#102
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-356-7474
Practice Address - Fax:970-356-2474
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO65031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice