Provider Demographics
NPI:1457342487
Name:SMITH, ROBERT HENRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HENRY
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:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-0535
Mailing Address - Country:US
Mailing Address - Phone:270-692-3265
Mailing Address - Fax:270-692-6368
Practice Address - Street 1:503 N SPALDING AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1022
Practice Address - Country:US
Practice Address - Phone:270-692-3265
Practice Address - Fax:270-692-6368
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60055944Medicaid