Provider Demographics
NPI:1639231707
Name:SMITH, MARK G (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
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 1:2936 S 86TH CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3099
Mailing Address - Country:US
Mailing Address - Phone:402-393-2484
Mailing Address - Fax:402-393-2490
Practice Address - Street 1:2936 S 86TH CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3099
Practice Address - Country:US
Practice Address - Phone:402-393-2484
Practice Address - Fax:402-393-2490
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice