Provider Demographics
NPI:1770724833
Name:SMITH, DONALD G JR (DDS)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:G
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:G
Other - Last Name:SMITH
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2104 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-4640
Mailing Address - Country:US
Mailing Address - Phone:402-371-6566
Mailing Address - Fax:
Practice Address - Street 1:2104 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4640
Practice Address - Country:US
Practice Address - Phone:402-371-6566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE42941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025683100Medicaid