Provider Demographics
NPI:1073835328
Name:SMITH, WILLIAM EDGAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:EDGAR
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:E
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:BLDG 2441 21ST STREET
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223
Mailing Address - Country:US
Mailing Address - Phone:270-798-8751
Mailing Address - Fax:270-956-0266
Practice Address - Street 1:BLDG 2441 21ST STREET
Practice Address - Street 2:US ARMY DENTAL ACTIVITY
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-798-8751
Practice Address - Fax:270-956-0266
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS7100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-1943033OtherTAX ID