Provider Demographics
NPI:1245324904
Name:SMITH, ROGER D (DMD PSC)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 RUSSELL RD STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-1054
Mailing Address - Country:US
Mailing Address - Phone:270-384-5155
Mailing Address - Fax:270-384-6757
Practice Address - Street 1:933 RUSSELL RD STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-1054
Practice Address - Country:US
Practice Address - Phone:270-384-5155
Practice Address - Fax:270-384-6757
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice