Provider Demographics
NPI:1265578934
Name:SMITH, DARRYL VICTOR (DDS)
Entity type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:VICTOR
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 1:571 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-2356
Mailing Address - Country:US
Mailing Address - Phone:502-227-2740
Mailing Address - Fax:502-226-3282
Practice Address - Street 1:571 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-2356
Practice Address - Country:US
Practice Address - Phone:502-227-2740
Practice Address - Fax:502-226-3282
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60061926Medicaid