Provider Demographics
NPI:1164420758
Name:SMITH, VINCENT JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:SMITH
Suffix:JR
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 1:6925 WILLOW ST NW
Mailing Address - Street 2:B-106
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-2000
Mailing Address - Country:US
Mailing Address - Phone:202-723-8284
Mailing Address - Fax:202-882-1127
Practice Address - Street 1:6925 WILLOW STREET
Practice Address - Street 2:B-106
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012
Practice Address - Country:US
Practice Address - Phone:202-723-8284
Practice Address - Fax:202-882-1127
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1000836122300000X
MD14260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC05301900Medicaid