Provider Demographics
NPI:1134263478
Name:SMITH, ANDREW MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MARK
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 1:6040 FASHION BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5415
Mailing Address - Country:US
Mailing Address - Phone:801-262-6661
Mailing Address - Fax:801-268-4820
Practice Address - Street 1:6040 FASHION BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5415
Practice Address - Country:US
Practice Address - Phone:801-262-6661
Practice Address - Fax:801-268-4820
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5322791-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist