Provider Demographics
NPI:1710083142
Name:SMITH, EDWIN EARL (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:EARL
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:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906
Mailing Address - Country:US
Mailing Address - Phone:606-546-8217
Mailing Address - Fax:606-545-7261
Practice Address - Street 1:16 WINDBURN DR
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-7843
Practice Address - Country:US
Practice Address - Phone:606-546-8217
Practice Address - Fax:606-545-7261
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY63811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60063815Medicaid