Provider Demographics
NPI:1942373584
Name:SMITH, IVAN J (DMD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1190 EDGEWOOD AVE W
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-3419
Mailing Address - Country:US
Mailing Address - Phone:904-764-4549
Mailing Address - Fax:904-764-2263
Practice Address - Street 1:1190 EDGEWOOD AVE W
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-3419
Practice Address - Country:US
Practice Address - Phone:904-764-4549
Practice Address - Fax:904-764-2263
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL00148051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice