MEDICARE: JUSTIN R SMITH DMD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1215659776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUSTIN R SMITH DMD PA

Provider Business Mailing Address
First Line	:	2407 SAINT ANDREWS BLVD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2170
Country	:	US
Telephone Number	:	850-763-5021
Fax Number	:

Provider Business Practice Location Address
First Line	:	2407 SAINT ANDREWS BLVD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2170
Country	:	US
Telephone Number	:	850-763-5021
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING LEAD
Name	:	JENNY GARCIA
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	09/13/2022
Last Update Date	:	09/13/2022

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