Provider Demographics
NPI:1750462214
Name:SMITH, NATHAN RANDALL (DMD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:RANDALL
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 1:3220 5TH AVE S #DEW2002
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35222-2309
Mailing Address - Country:US
Mailing Address - Phone:205-975-9842
Mailing Address - Fax:
Practice Address - Street 1:3220 5TH AVE S # DEW2002
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35222-2309
Practice Address - Country:US
Practice Address - Phone:205-975-9842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL54361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL107861Medicaid
AL123847Medicaid
AL510-48371OtherBLUE CROSS BLUE SHIELD WESTERN DENTAL
AL009910280Medicaid
AL515-41700OtherBLUE CROSS BLUE SHIELD EASTERN DENTAL