Healthcare Provider Details

I. General information

NPI: 1124151345
Provider Name (Legal Business Name): ANDREA M. SMITH D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 DALE BUMPERS DR
FORREST CITY AR
72335-2695
US

IV. Provider business mailing address

2301 EDGEWOOD PARK CV
MEMPHIS TN
38104-4392
US

V. Phone/Fax

Practice location:
  • Phone: 870-494-4200
  • Fax:
Mailing address:
  • Phone: 901-490-6889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number7849
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: