Provider Demographics
NPI:1700974136
Name:SMITH, JOHN PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PATRICK
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 1:1114 ANN ST STE 1-PO # 487
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-1938
Mailing Address - Country:US
Mailing Address - Phone:262-728-8232
Mailing Address - Fax:262-728-8259
Practice Address - Street 1:1114 ANN ST STE 1-PO # 487
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-1938
Practice Address - Country:US
Practice Address - Phone:262-728-8232
Practice Address - Fax:262-728-8259
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33495800Medicaid