Provider Demographics
NPI:1801906615
Name:SMITH, DANE E (DDS)
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:E
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 1:3500 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1108
Mailing Address - Country:US
Mailing Address - Phone:541-756-3683
Mailing Address - Fax:541-756-1974
Practice Address - Street 1:565 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9702
Practice Address - Country:US
Practice Address - Phone:541-469-5373
Practice Address - Fax:541-412-0177
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD47731223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164848Medicaid
ORD4773OtherDENTAL LICENSE #
ORT68142Medicare UPIN
ORD4773OtherDENTAL LICENSE #