Provider Demographics
NPI:1174634489
Name:SMITH, DOUGLAS PARKER (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:PARKER
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 1:142 COUNTRY BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-8848
Mailing Address - Country:US
Mailing Address - Phone:417-230-5511
Mailing Address - Fax:
Practice Address - Street 1:516 W MCCORD ST
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-1424
Practice Address - Country:US
Practice Address - Phone:417-451-0977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040057821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400568002Medicaid