Provider Demographics
NPI:1174582928
Name:SMITH, PAUL R (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
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 1:5345 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2764
Mailing Address - Country:US
Mailing Address - Phone:563-359-1601
Mailing Address - Fax:563-355-7111
Practice Address - Street 1:5345 SPRING STREET
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-0000
Practice Address - Country:US
Practice Address - Phone:563-359-1601
Practice Address - Fax:563-355-7111
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA78501223S0112X
MD88461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0142778Medicaid
IA142778Medicaid
IA2142778Medicaid
54435Medicare UPIN
IA57072Medicare ID - Type UnspecifiedCLINTON MEDICARE #
IA142778Medicaid
IA2142778Medicaid