Provider Demographics
NPI:1629778675
Name:SMITH, MARK D (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
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 1:124 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-3618
Mailing Address - Country:US
Mailing Address - Phone:478-237-7979
Mailing Address - Fax:478-237-2485
Practice Address - Street 1:124 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3618
Practice Address - Country:US
Practice Address - Phone:478-237-7979
Practice Address - Fax:478-237-2485
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA110211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice