Provider Demographics
NPI:1962441535
Name:SMITH, THOMAS IVERSON (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:IVERSON
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 1:23 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3773
Mailing Address - Country:US
Mailing Address - Phone:912-265-7273
Mailing Address - Fax:912-261-2792
Practice Address - Street 1:23 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3773
Practice Address - Country:US
Practice Address - Phone:912-265-7273
Practice Address - Fax:912-261-2792
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA110221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA681685OtherUNITED CONCORDIA PROVIDER