Provider Demographics
NPI:1699405878
Name:SMITH, CARSON (DMD)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13773 NE 136TH LOOP UNIT 6109
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-6936
Mailing Address - Country:US
Mailing Address - Phone:321-262-2665
Mailing Address - Fax:
Practice Address - Street 1:540 FIELDCREST DR
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32162-4601
Practice Address - Country:US
Practice Address - Phone:352-205-7667
Practice Address - Fax:352-205-8754
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL269331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice