Provider Demographics
NPI:1073665691
Name:SMITH, DON EDWIN JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DON
Middle Name:EDWIN
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:300 W ADAMS ST
Mailing Address - Street 2:P.O. BOX 627
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3644
Mailing Address - Country:US
Mailing Address - Phone:662-289-2570
Mailing Address - Fax:662-289-2580
Practice Address - Street 1:300 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3644
Practice Address - Country:US
Practice Address - Phone:662-289-2570
Practice Address - Fax:662-289-2580
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2961-961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660161Medicaid