Provider Demographics
NPI:1891960399
Name:SMITH, JOHN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-1475
Mailing Address - Country:US
Mailing Address - Phone:405-257-7318
Mailing Address - Fax:405-257-2696
Practice Address - Street 1:HWY 56 & 270 JUNCTION
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884-1475
Practice Address - Country:US
Practice Address - Phone:405-257-7318
Practice Address - Fax:405-257-2696
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice