Provider Demographics
NPI:1053626671
Name:SMITH, NICHOLAS A (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SOUTHSHORE LN
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-9111
Mailing Address - Country:US
Mailing Address - Phone:971-678-4741
Mailing Address - Fax:
Practice Address - Street 1:2074 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-3372
Practice Address - Country:US
Practice Address - Phone:541-880-2090
Practice Address - Fax:541-880-2092
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist