Provider Demographics
NPI:1356012702
Name:SMITH, JOHN LEE
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEE
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 1:20 WILLIAMS BLVD APT 1A
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2419
Mailing Address - Country:US
Mailing Address - Phone:703-946-5299
Mailing Address - Fax:
Practice Address - Street 1:20 WILLIAMS BLVD APT 1A
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2419
Practice Address - Country:US
Practice Address - Phone:703-946-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist