Provider Demographics
NPI:1518302538
Name:SMITH, JOHANNA S (DDS)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 WALNUT RIDGE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-8803
Mailing Address - Country:US
Mailing Address - Phone:262-367-4255
Mailing Address - Fax:
Practice Address - Street 1:625 WALNUT RIDGE DR STE 102
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-8803
Practice Address - Country:US
Practice Address - Phone:262-367-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7087-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice