Provider Demographics
NPI:1184746307
Name:SMITH, KEVIN CLARK (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CLARK
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 1:610 NINTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:MD
Mailing Address - Zip Code:21716
Mailing Address - Country:US
Mailing Address - Phone:301-834-6441
Mailing Address - Fax:301-834-6546
Practice Address - Street 1:610 NINTH AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:MD
Practice Address - Zip Code:21716-1828
Practice Address - Country:US
Practice Address - Phone:301-834-6441
Practice Address - Fax:301-834-6546
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice