Provider Demographics
NPI:1235414558
Name:JASON R. SMITH, DMD, FAMILY DENTISTRY
Entity Type:Organization
Organization Name:JASON R. SMITH, DMD, FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-524-5422
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:MUNFORDVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42765-0068
Mailing Address - Country:US
Mailing Address - Phone:270-524-5422
Mailing Address - Fax:270-524-5847
Practice Address - Street 1:663 MAIN ST
Practice Address - Street 2:
Practice Address - City:MUNFORDVILLE
Practice Address - State:KY
Practice Address - Zip Code:42765-9436
Practice Address - Country:US
Practice Address - Phone:270-524-5422
Practice Address - Fax:270-524-5847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY80901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60003977Medicaid