Provider Demographics
NPI:1114013182
Name:SMITHEY, WOODY LYLE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:WOODY
Middle Name:LYLE
Last Name:SMITHEY
Suffix:JR
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 1:900 S VIENNA ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5830
Mailing Address - Country:US
Mailing Address - Phone:318-251-0334
Mailing Address - Fax:318-255-3538
Practice Address - Street 1:900 S VIENNA ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5830
Practice Address - Country:US
Practice Address - Phone:318-251-0334
Practice Address - Fax:318-255-3538
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 41151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1841153Medicaid
LA842233OtherUNITED CONCORDIA