Provider Demographics
NPI:1609186576
Name:SMITH, JACKIE L (DDS)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
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 1:154 WELFORD LN
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3418
Mailing Address - Country:US
Mailing Address - Phone:417-332-2980
Mailing Address - Fax:
Practice Address - Street 1:154 WELFORD LN
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3418
Practice Address - Country:US
Practice Address - Phone:417-332-2980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007034336122300000X
AR1991122300000X
TN1935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist