Healthcare Provider Details

I. General information

NPI: 1235492190
Provider Name (Legal Business Name): TIMOTHY W SMITH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 AL HIGHWAY 69 S
HANCEVILLE AL
35077-3405
US

IV. Provider business mailing address

655 AL HIGHWAY 69 S
HANCEVILLE AL
35077-3405
US

V. Phone/Fax

Practice location:
  • Phone: 256-287-1250
  • Fax: 256-287-1253
Mailing address:
  • Phone: 256-287-1250
  • Fax: 256-287-1253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5917 C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: