Provider Demographics
NPI:1235153768
Name:FREDERIC W. SMITH DMD, MD, LLC
Entity Type:Organization
Organization Name:FREDERIC W. SMITH DMD, MD, LLC
Other - Org Name:THREE RIVERS ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:541-276-1061
Mailing Address - Street 1:1100 SOUTHGATE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-3974
Mailing Address - Country:US
Mailing Address - Phone:541-276-1061
Mailing Address - Fax:541-276-0674
Practice Address - Street 1:1100 SOUTHGATE
Practice Address - Street 2:SUITE 11
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-3974
Practice Address - Country:US
Practice Address - Phone:541-276-1061
Practice Address - Fax:541-276-0674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD 87191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty