Provider Demographics
NPI:1497758122
Name:SMITH, JOHN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:468 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-3413
Mailing Address - Country:US
Mailing Address - Phone:440-582-0612
Mailing Address - Fax:440-582-0622
Practice Address - Street 1:15380 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-4824
Practice Address - Country:US
Practice Address - Phone:440-888-6300
Practice Address - Fax:440-888-6329
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175871223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0596029Medicaid
483091OtherUNITED CONCORDIA INSURANC
OHU52140Medicare UPIN
OHSM0772151Medicare ID - Type Unspecified