Provider Demographics
NPI:1912075979
Name:SMITH, NATHAN WADSWORTH (DMD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:WADSWORTH
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 1:1669 E INDIGO ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-3218
Mailing Address - Country:US
Mailing Address - Phone:480-254-2763
Mailing Address - Fax:
Practice Address - Street 1:2058 S DOBSON RD STE 12
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6455
Practice Address - Country:US
Practice Address - Phone:480-838-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ64081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1902610OtherUNITED CONCORDIA