Provider Demographics
NPI:1134478647
Name:ROBERT E. SMITH DDS MPH
Entity Type:Organization
Organization Name:ROBERT E. SMITH DDS MPH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MADGIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-732-4747
Mailing Address - Street 1:115 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2154
Mailing Address - Country:US
Mailing Address - Phone:203-732-4747
Mailing Address - Fax:203-734-4101
Practice Address - Street 1:115 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-2154
Practice Address - Country:US
Practice Address - Phone:203-732-4747
Practice Address - Fax:203-734-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0108101223G0001X
CT007110124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty