Provider Demographics
NPI:1689888158
Name:KEVIN J SMITH DDS PLLC
Entity Type:Organization
Organization Name:KEVIN J SMITH DDS PLLC
Other - Org Name:PRAIRIE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-944-9800
Mailing Address - Street 1:10001 NE 117TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-1504
Mailing Address - Country:US
Mailing Address - Phone:360-944-9800
Mailing Address - Fax:
Practice Address - Street 1:10001 NE 117TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-1504
Practice Address - Country:US
Practice Address - Phone:360-944-9800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60171756122300000X
WADE000075321223G0001X
WADE000101951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty