Provider Demographics
NPI:1811963390
Name:SMITH, DEAN A (MD)
Entity type:Individual
Prefix:MR
First Name:DEAN
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-0591
Mailing Address - Country:US
Mailing Address - Phone:843-497-8538
Mailing Address - Fax:843-449-2333
Practice Address - Street 1:305 WILDWOOD CIR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4748
Practice Address - Country:US
Practice Address - Phone:843-497-8538
Practice Address - Fax:843-449-2333
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20127207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00356Medicaid
SCN00356Medicaid
SCC316333921Medicare PIN
SCC316330281Medicare PIN