Provider Demographics
NPI:1174631089
Name:SMART, GREG L (DDS)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:L
Last Name:SMART
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 1:7117 GREEN BAY ROAD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404
Mailing Address - Country:US
Mailing Address - Phone:262-942-7000
Mailing Address - Fax:262-942-7117
Practice Address - Street 1:7117 GREEN BAY ROAD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404
Practice Address - Country:US
Practice Address - Phone:262-942-7000
Practice Address - Fax:262-942-7117
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4242-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33706300Medicaid