Provider Demographics
NPI:1255490223
Name:SMITH, MARK ALAN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 W LAMBERTH RD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092
Mailing Address - Country:US
Mailing Address - Phone:903-893-8030
Mailing Address - Fax:903-868-0633
Practice Address - Street 1:2011 W LAMBERTH RD
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092
Practice Address - Country:US
Practice Address - Phone:903-893-8030
Practice Address - Fax:903-868-0633
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX179961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice