Provider Demographics
NPI:1154324002
Name:SMITH, SCOTT RAYMOND (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RAYMOND
Last Name:SMITH
Suffix:
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 1:770 RIVERSIDE AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1465
Mailing Address - Country:US
Mailing Address - Phone:517-265-5577
Mailing Address - Fax:517-265-8068
Practice Address - Street 1:770 RIVERSIDE AVE
Practice Address - Street 2:STE 201
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1465
Practice Address - Country:US
Practice Address - Phone:517-265-5577
Practice Address - Fax:517-265-8068
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI125561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice