Provider Demographics
NPI:1497763577
Name:SMITH, DAVID GORDON (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GORDON
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-1026
Mailing Address - Country:US
Mailing Address - Phone:208-452-4303
Mailing Address - Fax:208-452-3271
Practice Address - Street 1:715 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2583
Practice Address - Country:US
Practice Address - Phone:208-452-4303
Practice Address - Fax:208-452-3271
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-17911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice