Provider Demographics
NPI:1184304081
Name:SMITH, KADIJAH S (DDS)
Entity type:Individual
Prefix:
First Name:KADIJAH
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N ARCADIA AVE APT 224
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2153
Mailing Address - Country:US
Mailing Address - Phone:901-574-8930
Mailing Address - Fax:
Practice Address - Street 1:3120 STONECREST BLVD STE 100
Practice Address - Street 2:
Practice Address - City:STONECREST
Practice Address - State:GA
Practice Address - Zip Code:30038-2693
Practice Address - Country:US
Practice Address - Phone:770-484-4994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist