Provider Demographics
NPI:1881704559
Name:SMITH, DARYL EDWARD
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 NEW BERLIN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218
Mailing Address - Country:US
Mailing Address - Phone:904-696-3336
Mailing Address - Fax:904-696-3970
Practice Address - Street 1:376 NEW BERLIN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218
Practice Address - Country:US
Practice Address - Phone:904-696-3336
Practice Address - Fax:904-696-3970
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13001122300000X
FLDN0013001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist