Provider Demographics
NPI:1114917010
Name:SMITH, J RANDALL (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:RANDALL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-4426
Mailing Address - Country:US
Mailing Address - Phone:931-455-0146
Mailing Address - Fax:931-393-3863
Practice Address - Street 1:205 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-4426
Practice Address - Country:US
Practice Address - Phone:931-455-0146
Practice Address - Fax:931-393-3863
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
844210OtherUNITED CONCORDIA
TN0160873OtherBLUE CROSS BLUE SHIELD
0006684OtherDORAL DENTAL