Provider Demographics
NPI:1790987790
Name:SMITH, EDGAR LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:LEE
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 1:1820 80TH ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50322-5602
Mailing Address - Country:US
Mailing Address - Phone:515-276-0830
Mailing Address - Fax:
Practice Address - Street 1:1820 80TH JSTREET
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50322-5602
Practice Address - Country:US
Practice Address - Phone:515-276-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA54031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1039107Medicaid