Healthcare Provider Details

I. General information

NPI: 1235625047
Provider Name (Legal Business Name): JOHN SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31ST MEDICAL GROUP UNIT 6180
APO AE
09604-6180
US

IV. Provider business mailing address

N67W32380 WILDWOOD POINT RD
HARTLAND WI
53029-8504
US

V. Phone/Fax

Practice location:
  • Phone: 314-632-5060
  • Fax:
Mailing address:
  • Phone: 262-751-6125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD14085
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7844
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: