Provider Demographics
NPI:1831754795
Name:SMITH, RYAN DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DAVID
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:BLDG D-3836 ARDENNES ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-9061
Mailing Address - Fax:
Practice Address - Street 1:BLDG 2441 21ST ST
Practice Address - Street 2:
Practice Address - City:FT. CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:43332
Practice Address - Country:US
Practice Address - Phone:270-798-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032265122300000X
TN124491223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist