Provider Demographics
NPI:1629075130
Name:SMITH, JOHNNY LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:LEE
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 1:9276 W UNION HILLS DR
Mailing Address - Street 2:STE. A
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8158
Mailing Address - Country:US
Mailing Address - Phone:623-972-6137
Mailing Address - Fax:623-972-6334
Practice Address - Street 1:9276 W UNION HILLS DR
Practice Address - Street 2:STE. A
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8158
Practice Address - Country:US
Practice Address - Phone:623-972-6137
Practice Address - Fax:623-972-6334
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice