Provider Demographics
NPI:1912045709
Name:SMITH, GARY MICHAEL (DDS MSD SC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS MSD SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2600 N MAYFAIR RD
Mailing Address - Street 2:SUITE 825
Mailing Address - City:WAWWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-257-3170
Mailing Address - Fax:414-257-2054
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE 825
Practice Address - City:WAWWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-257-3170
Practice Address - Fax:414-257-2054
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI492G1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics