Provider Demographics
NPI:1225040116
Name:SMART, JONATHAN DEAN (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DEAN
Last Name:SMART
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2342 NW PROFESSIONAL DR.
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-757-7708
Mailing Address - Fax:541-738-7192
Practice Address - Street 1:2342 NW PROFESSIONAL DR.
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-757-7708
Practice Address - Fax:541-738-7192
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5765733-99221223G0001X
ORD82561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1702399OtherUNITED CONCORDIA
UT5765733OtherCIGNA
UT57657339900001OtherBC/BS
UT885140OtherDMBA
UT77777OtherDELTA
UT84083OtherPEHP