Provider Demographics
NPI:1558854265
Name:SMITH, EVAN R (DMD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:R
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 1:99 ST PAUL DR
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1020
Mailing Address - Country:US
Mailing Address - Phone:717-263-3123
Mailing Address - Fax:
Practice Address - Street 1:99 ST PAUL DR
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1020
Practice Address - Country:US
Practice Address - Phone:717-263-3123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041706122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS041706OtherSTATE LICENSE