Provider Demographics
NPI:1376703066
Name:SHELBY J. SMITH, DDS, MS, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHELBY J. SMITH, DDS, MS, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:925-755-5115
Mailing Address - Street 1:2213 BUCHANAN RD STE 112
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-4265
Mailing Address - Country:US
Mailing Address - Phone:925-755-5115
Mailing Address - Fax:925-755-5003
Practice Address - Street 1:2213 BUCHANAN RD STE 112
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4265
Practice Address - Country:US
Practice Address - Phone:925-755-5115
Practice Address - Fax:925-755-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38482261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental