Provider Demographics
NPI:1821207374
Name:SMITH, DOUGLAS EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EDWARD
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 1:5102 PAULSEN ST BLDG 8
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4624
Mailing Address - Country:US
Mailing Address - Phone:912-655-8855
Mailing Address - Fax:912-335-3416
Practice Address - Street 1:5102 PAULSEN ST BLDG 8
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4624
Practice Address - Country:US
Practice Address - Phone:912-655-8855
Practice Address - Fax:912-335-3416
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGADN0080861223X0400X
GA80861223X0400X
GADN008086332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA274736629OtherTRICARE PROVIDER & DME SUPPLIER
GA6719510001Medicare PIN