Provider Demographics
NPI:1811985948
Name:SMITH, BRIAN M (DMD MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E LEHIGH AVE
Mailing Address - Street 2:PM
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1011
Mailing Address - Country:US
Mailing Address - Phone:215-707-3613
Mailing Address - Fax:215-707-5405
Practice Address - Street 1:101 E LEHIGH AVE
Practice Address - Street 2:PM
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1011
Practice Address - Country:US
Practice Address - Phone:215-707-3613
Practice Address - Fax:215-707-5405
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024550L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012478530006Medicaid
PAT29985Medicare UPIN