MEDICARE: CORY M. SMITH, DMD, L.L.C.

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1962727693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORY M. SMITH, DMD, L.L.C.

Provider Business Mailing Address
First Line	:	505 N 2ND AVE
Second Line	:
City	:	STAYTON
State	:	OR
Zip	:	97383-1715
Country	:	US
Telephone Number	:	503-769-3366
Fax Number	:	503-769-5501

Provider Business Practice Location Address
First Line	:	505 N 2ND AVE
Second Line	:
City	:	STAYTON
State	:	OR
Zip	:	97383-1715
Country	:	US
Telephone Number	:	503-769-3366
Fax Number	:	503-769-5501

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CORY MERIL SMITH
Credential	:	DMD
Telephone Number	:	503-476-5512

Provider Enumeration Date	:	04/06/2010
Last Update Date	:	04/06/2010

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