Provider Demographics
NPI:1144561002
Name:BRIAN K. SMITH, D.D.S., M.D., INC.
Entity Type:Organization
Organization Name:BRIAN K. SMITH, D.D.S., M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:D,D,S, MD
Authorized Official - Phone:216-228-4232
Mailing Address - Street 1:14701 DETROIT AVE
Mailing Address - Street 2:SUITE 333
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4109
Mailing Address - Country:US
Mailing Address - Phone:216-228-4232
Mailing Address - Fax:216-228-9136
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:SUITE 333
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4109
Practice Address - Country:US
Practice Address - Phone:216-228-4232
Practice Address - Fax:216-228-9136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30183741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2127513Medicaid
OH2127513Medicaid