Provider Demographics
NPI:1700851581
Name:SMITH, JESSE WAYLON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:WAYLON
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 1:1100 W WELLS ST
Mailing Address - Street 2:#1107
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-2332
Mailing Address - Country:US
Mailing Address - Phone:414-397-0093
Mailing Address - Fax:
Practice Address - Street 1:1801 W WISCONSIN AVE
Practice Address - Street 2:#206
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2186
Practice Address - Country:US
Practice Address - Phone:414-288-6508
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5684-0151223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics