Provider Demographics
NPI:1992966261
Name:SMITH, CHRISTOPHER BLAKE (DMD, MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:BLAKE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 19TH ST S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-5628
Mailing Address - Country:US
Mailing Address - Phone:205-933-2772
Mailing Address - Fax:
Practice Address - Street 1:1500 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-5628
Practice Address - Country:US
Practice Address - Phone:205-933-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL5611122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist