Provider Demographics
NPI:1740256379
Name:SMITH, MICHAEL T (DDS,PC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 4TH ST
Mailing Address - Street 2:P.O.BOX 264
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-1851
Mailing Address - Country:US
Mailing Address - Phone:765-675-2432
Mailing Address - Fax:
Practice Address - Street 1:114 4TH ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-1851
Practice Address - Country:US
Practice Address - Phone:765-675-2432
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008617A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice