Provider Demographics
NPI:1043302268
Name:SMITH, DONOVAN (DDS)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:
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 1:2149 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:LA
Mailing Address - Zip Code:70583-5301
Mailing Address - Country:US
Mailing Address - Phone:337-593-0300
Mailing Address - Fax:
Practice Address - Street 1:2149 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583-5301
Practice Address - Country:US
Practice Address - Phone:337-593-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4814122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist