Provider Demographics
NPI:1275500167
Name:A. TODD SMITH, DDS PA
Entity Type:Organization
Organization Name:A. TODD SMITH, DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:A
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-765-9550
Mailing Address - Street 1:1601 SOUTH HAWTHORNE ROAD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4127
Mailing Address - Country:US
Mailing Address - Phone:336-765-9550
Mailing Address - Fax:336-765-9552
Practice Address - Street 1:1601 SOUTH HAWTHORNE ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4127
Practice Address - Country:US
Practice Address - Phone:336-765-9550
Practice Address - Fax:336-765-9552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4949204E00000X
NC3596204E00000X
NC5848204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7997761Medicaid
NC8997869Medicaid
0382Medicare ID - Type UnspecifiedGROUP
T97074Medicare UPIN
T95442Medicare UPIN
NC8997869Medicaid
NC7997761Medicaid
2428626Medicare ID - Type Unspecified
241381Medicare ID - Type Unspecified