Provider Demographics
NPI:1497061634
Name:SMITH, JUSTIN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:R
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 1:2407 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2170
Mailing Address - Country:US
Mailing Address - Phone:850-763-5021
Mailing Address - Fax:
Practice Address - Street 1:2407 SAINT ANDREWS BLVD STE A
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2170
Practice Address - Country:US
Practice Address - Phone:850-763-5021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD0005975-C1122300000X
FLDN 191941223G0001X
FLDN191941223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice