Provider Demographics
NPI:1740759810
Name:SMITH, DAVID DEWAYNE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DEWAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:FOXWORTH
Mailing Address - State:MS
Mailing Address - Zip Code:39483-4868
Mailing Address - Country:US
Mailing Address - Phone:601-395-7602
Mailing Address - Fax:
Practice Address - Street 1:17 DAISY LN
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-4868
Practice Address - Country:US
Practice Address - Phone:601-395-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800427553347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker