Provider Demographics
NPI:1780718411
Name:SMITH, DAMONE E (DDS)
Entity type:Individual
Prefix:DR
First Name:DAMONE
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12651 W SUNRISE BLVD
Mailing Address - Street 2:#304
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-0906
Mailing Address - Country:US
Mailing Address - Phone:954-845-0098
Mailing Address - Fax:954-845-0280
Practice Address - Street 1:12651 W SUNRISE BLVD
Practice Address - Street 2:#304
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-0906
Practice Address - Country:US
Practice Address - Phone:954-845-0098
Practice Address - Fax:954-845-0280
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN164481223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690057796Medicaid
FL201435221OtherTAX ID
FL690057701Medicaid