Provider Demographics
NPI:1700015054
Name:SMITH, MICHAEL B (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 MEADOWCREST STREET
Mailing Address - Street 2:STE 100
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056
Mailing Address - Country:US
Mailing Address - Phone:504-392-6057
Mailing Address - Fax:504-391-2429
Practice Address - Street 1:250 MEADOWCREST STREET
Practice Address - Street 2:STE 100
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056
Practice Address - Country:US
Practice Address - Phone:504-392-6057
Practice Address - Fax:504-391-2429
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5356122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist