Provider Demographics
NPI:1639679087
Name:MICHAEL SMITH DMD, LLC
Entity Type:Organization
Organization Name:MICHAEL SMITH DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-235-5141
Mailing Address - Street 1:16 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1425
Mailing Address - Country:US
Mailing Address - Phone:618-235-5141
Mailing Address - Fax:618-235-2155
Practice Address - Street 1:16 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1425
Practice Address - Country:US
Practice Address - Phone:618-235-5141
Practice Address - Fax:618-235-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental