Provider Demographics
NPI:1316001795
Name:SMITH, PHILIP J (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:J
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 1:7455 E TANQUE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3477
Mailing Address - Country:US
Mailing Address - Phone:520-745-2454
Mailing Address - Fax:520-745-0014
Practice Address - Street 1:7455 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3477
Practice Address - Country:US
Practice Address - Phone:520-745-2454
Practice Address - Fax:520-745-0014
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD16651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ765597Medicaid