Provider Demographics
NPI:1699830265
Name:SMITH, MARK WALLACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WALLACE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 EAST STATE ROAD 252
Mailing Address - Street 2:
Mailing Address - City:EDINBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:46124
Mailing Address - Country:US
Mailing Address - Phone:812-526-2026
Mailing Address - Fax:812-526-2844
Practice Address - Street 1:7650 EAST STATE ROAD 252
Practice Address - Street 2:
Practice Address - City:EDINBURGH
Practice Address - State:IN
Practice Address - Zip Code:46124
Practice Address - Country:US
Practice Address - Phone:812-526-2026
Practice Address - Fax:812-526-2844
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice