Provider Demographics
NPI:1679567796
Name:SMITH, JOHN DAVID (DR)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-8629
Mailing Address - Country:US
Mailing Address - Phone:850-785-4522
Mailing Address - Fax:
Practice Address - Street 1:12832 NW CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32424
Practice Address - Country:US
Practice Address - Phone:850-643-2415
Practice Address - Fax:850-643-5689
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLN3799122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist