Provider Demographics
NPI:1831105089
Name:SMITH, MICHAEL ROY (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROY
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 547
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-0547
Mailing Address - Country:US
Mailing Address - Phone:606-549-0374
Mailing Address - Fax:606-549-0426
Practice Address - Street 1:821 SOUTH HWY 25 W
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769
Practice Address - Country:US
Practice Address - Phone:606-549-0374
Practice Address - Fax:606-549-0426
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60052495Medicaid