Provider Demographics
NPI:1073798971
Name:SMITH, JACLYN N (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:N
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SH 71 W STE 200
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-4111
Mailing Address - Country:US
Mailing Address - Phone:512-321-4445
Mailing Address - Fax:512-321-7300
Practice Address - Street 1:301 SH 71 W STE 200
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-4111
Practice Address - Country:US
Practice Address - Phone:512-321-4445
Practice Address - Fax:512-321-7300
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice