Provider Demographics
NPI:1326066481
Name:SMITH, DUSTIN G (DMD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73
Mailing Address - Street 2:1718 SOUTH MAIN STREET
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-0073
Mailing Address - Country:US
Mailing Address - Phone:601-795-8024
Mailing Address - Fax:601-795-0745
Practice Address - Street 1:1718 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-4287
Practice Address - Country:US
Practice Address - Phone:601-795-8024
Practice Address - Fax:601-795-0745
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3142-001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS781236OtherUNITED CONCORDIA
MS00660344Medicaid