Provider Demographics
NPI:1558743328
Name:SMITH, MATTHEW (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:15492 MAX LEGGETT PARKWAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218
Mailing Address - Country:US
Mailing Address - Phone:904-414-4500
Mailing Address - Fax:
Practice Address - Street 1:15492 MAX LEGGETT PARKWAY
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218
Practice Address - Country:US
Practice Address - Phone:904-414-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002025501223G0001X
FLDN240561223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice