Provider Demographics
NPI:1760753099
Name:G. TREVOR SMITH, DDS, PC
Entity Type:Organization
Organization Name:G. TREVOR SMITH, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:TREVOR
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-785-2574
Mailing Address - Street 1:60 E STATE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2637
Mailing Address - Country:US
Mailing Address - Phone:801-785-2574
Mailing Address - Fax:801-785-2697
Practice Address - Street 1:60 E STATE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2637
Practice Address - Country:US
Practice Address - Phone:801-785-2574
Practice Address - Fax:801-785-2697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT342046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529432975012Medicaid