Provider Demographics
NPI:1811905854
Name:SMITH, ELDRIDGE CHARLES (PERIODONTIST DDS)
Entity type:Individual
Prefix:DR
First Name:ELDRIDGE
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:PERIODONTIST DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 CLAIREMONT DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5831
Mailing Address - Country:US
Mailing Address - Phone:858-272-0070
Mailing Address - Fax:858-272-0072
Practice Address - Street 1:3804 CLAIREMONT DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5831
Practice Address - Country:US
Practice Address - Phone:858-272-0070
Practice Address - Fax:858-272-0072
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262311223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics