Provider Demographics
NPI:1902021074
Name:SMITH, JOHN WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
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 1:500 W 3RD AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-4502
Mailing Address - Country:US
Mailing Address - Phone:903-872-3043
Mailing Address - Fax:
Practice Address - Street 1:500 W 3RD AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-4502
Practice Address - Country:US
Practice Address - Phone:903-872-3043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX131361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice