Provider Demographics
NPI:1669573812
Name:SMITH, JONATHAN BRADFORD (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BRADFORD
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 1:1120 SPARKLEBERRY LANE EXT
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-7078
Mailing Address - Country:US
Mailing Address - Phone:803-462-3662
Mailing Address - Fax:803-462-6865
Practice Address - Street 1:1120 SPARKLEBERRY LANE EXT
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-7078
Practice Address - Country:US
Practice Address - Phone:803-462-3662
Practice Address - Fax:803-462-6865
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice