Provider Demographics
NPI:1568183473
Name:SMITH, EDWARD ANGUS JACKSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ANGUS JACKSON
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 1:5102 PAULSEN ST BLDG 8
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4624
Mailing Address - Country:US
Mailing Address - Phone:912-655-8855
Mailing Address - Fax:912-335-6564
Practice Address - Street 1:5102 PAULSEN ST BLDG 8
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4624
Practice Address - Country:US
Practice Address - Phone:912-655-8855
Practice Address - Fax:912-335-6564
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10315122300000X
FLDN27476122300000X
GADN1228901223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics