Provider Demographics
NPI:1619297587
Name:SMITH, ANDREW JACOB (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JACOB
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 1:2200 BRYANT WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1120
Mailing Address - Country:US
Mailing Address - Phone:541-884-1331
Mailing Address - Fax:
Practice Address - Street 1:2200 BRYANT WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1120
Practice Address - Country:US
Practice Address - Phone:541-884-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD91361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice