Provider Demographics
NPI:1821305939
Name:SMITH, JEFFREY T (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:T
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 1:988 E 1700 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-7940
Mailing Address - Country:US
Mailing Address - Phone:217-824-9248
Mailing Address - Fax:
Practice Address - Street 1:NAVY MEDICINE SUPPORT COMMAND, 2005 KNIGHT LANE BLDG H
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:904-542-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028469122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist