Provider Demographics
NPI:1811038243
Name:SMITH, TIMOTHY BLAIR (DMD)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:BLAIR
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 1246
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801
Mailing Address - Country:US
Mailing Address - Phone:541-276-4768
Mailing Address - Fax:541-276-9365
Practice Address - Street 1:310 SE 2ND
Practice Address - Street 2:SUITE 203
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801
Practice Address - Country:US
Practice Address - Phone:541-276-4768
Practice Address - Fax:541-276-9365
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR69281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice