Provider Demographics
NPI:1639191182
Name:SMITH, BRIAN ROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ROY
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 1:2125 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5314
Mailing Address - Country:US
Mailing Address - Phone:318-797-5812
Mailing Address - Fax:318-797-0390
Practice Address - Street 1:2125 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5314
Practice Address - Country:US
Practice Address - Phone:318-797-5812
Practice Address - Fax:318-797-0390
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA47521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC9163OtherBLUE CROSS/BLUE SHIELD
LA1847526Medicaid
TXT8B090451Medicaid
LAC9163OtherBLUE CROSS/BLUE SHIELD
LA1847526Medicaid