Provider Demographics
NPI:1992916175
Name:SMITH, MICHAEL SHANE (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
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 1:512 SCOTTER HILLS LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5541
Mailing Address - Country:US
Mailing Address - Phone:804-828-6498
Mailing Address - Fax:
Practice Address - Street 1:1202 CLEO WAY STE 3
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8356
Practice Address - Country:US
Practice Address - Phone:804-828-6498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013493122300000X
TNDS 7804122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist