Provider Demographics
NPI:1831279538
Name:SMITH, JUSTIN CRAIG (DMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CRAIG
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 3RD AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661
Mailing Address - Country:US
Mailing Address - Phone:208-642-9763
Mailing Address - Fax:208-642-3554
Practice Address - Street 1:1105 3RD AVE NORTH
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661
Practice Address - Country:US
Practice Address - Phone:208-642-9763
Practice Address - Fax:208-642-3554
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806078600Medicaid