Provider Demographics
NPI:1023084274
Name:SMITH, MICHAEL JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
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:MEDICAL ARTS BUILDING
Mailing Address - Street 2:91 LAKES ROAD
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950
Mailing Address - Country:US
Mailing Address - Phone:845-782-4220
Mailing Address - Fax:845-783-4846
Practice Address - Street 1:91 LAKES RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-2613
Practice Address - Country:US
Practice Address - Phone:845-782-4220
Practice Address - Fax:845-783-4846
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0352611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00727284Medicaid
T49495Medicare UPIN
NY00727284Medicaid