Provider Demographics
NPI:1952717753
Name:SMITH, JUDSON CHARLES
Entity Type:Individual
Prefix:DR
First Name:JUDSON
Middle Name:CHARLES
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 1:2323 N MAYFAIR RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1506
Mailing Address - Country:US
Mailing Address - Phone:414-257-1161
Mailing Address - Fax:414-257-0194
Practice Address - Street 1:2323 N MAYFAIR RD STE 102
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-257-1161
Practice Address - Fax:414-257-0194
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001751-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery