Provider Demographics
NPI:1790035426
Name:JONATHAN D SMART, DMD, PC
Entity Type:Organization
Organization Name:JONATHAN D SMART, DMD, PC
Other - Org Name:NORTHWEST DENTAL OF CORVALLIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-757-7708
Mailing Address - Street 1:2342 NW PROFESSIONAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-757-7708
Mailing Address - Fax:541-738-7192
Practice Address - Street 1:2342 NW PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-757-7708
Practice Address - Fax:541-738-7192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD82561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty