Provider Demographics
NPI:1265636625
Name:SMITH, KEVIN JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOSEPH
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 1:1325 S 8TH WAY
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-9237
Mailing Address - Country:US
Mailing Address - Phone:402-203-8776
Mailing Address - Fax:
Practice Address - Street 1:10001 NE 117TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-1504
Practice Address - Country:US
Practice Address - Phone:402-203-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 601717561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice