Provider Demographics
NPI:1144379819
Name:SMITH, ROY RANDALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:RANDALL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ROY
Other - Middle Name:RANDALL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5400 NEW COPELAND ROAD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-534-1171
Mailing Address - Fax:903-534-6054
Practice Address - Street 1:5400 NEW COPELAND RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3950
Practice Address - Country:US
Practice Address - Phone:903-534-1171
Practice Address - Fax:903-534-6054
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX125021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice