Provider Demographics
NPI:1356489462
Name:SMITH, JACK BRIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BRIAN
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 1:41 DOVER DR SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-8015
Mailing Address - Country:US
Mailing Address - Phone:423-309-6816
Mailing Address - Fax:
Practice Address - Street 1:160 THREE RIVERS DR NE
Practice Address - Street 2:STE. 1600
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-2303
Practice Address - Country:US
Practice Address - Phone:706-291-0095
Practice Address - Fax:706-291-0036
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129101223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics