Provider Demographics
NPI:1700813797
Name:SMITH, PAUL A (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
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 1:1060 W PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6602
Mailing Address - Country:US
Mailing Address - Phone:240-857-5029
Mailing Address - Fax:
Practice Address - Street 1:1060 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:240-857-5029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55851223X0400X, 1223G0001X, 122300000X
NC129971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855855Medicaid