Provider Demographics
NPI:1962664458
Name:DOUGLAS J. SMITH
Entity Type:Organization
Organization Name:DOUGLAS J. SMITH
Other - Org Name:DENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-356-9262
Mailing Address - Street 1:56 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2047
Mailing Address - Country:US
Mailing Address - Phone:208-356-9262
Mailing Address - Fax:208-356-4804
Practice Address - Street 1:56 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2047
Practice Address - Country:US
Practice Address - Phone:208-356-9262
Practice Address - Fax:208-356-4804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD14331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001193200Medicaid