Provider Demographics
NPI:1679670277
Name:SMITH, LARRY V (DDS MPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:V
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 OSOS ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:805-544-3434
Mailing Address - Fax:805-544-3443
Practice Address - Street 1:1231 OSOS ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-544-3434
Practice Address - Fax:805-544-3443
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA182701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD18270Medicaid