Provider Demographics
NPI:1265698666
Name:SMITH, EVAN A (DMD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:A
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 1:801 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5423
Mailing Address - Country:US
Mailing Address - Phone:208-343-4986
Mailing Address - Fax:208-343-4995
Practice Address - Street 1:801 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5423
Practice Address - Country:US
Practice Address - Phone:208-343-4986
Practice Address - Fax:208-343-4995
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4178122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist