Provider Demographics
NPI:1508451485
Name:SMITH, JUSTIN ROGER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ROGER
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 1:345 SAXONY RD STE 103
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2787
Mailing Address - Country:US
Mailing Address - Phone:760-632-2410
Mailing Address - Fax:
Practice Address - Street 1:345 SAXONY RD STE 103
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2787
Practice Address - Country:US
Practice Address - Phone:770-241-9192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25634122300000X
SC8727122300000X
CA105728122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist