Healthcare Provider Details

I. General information

NPI: 1316001795
Provider Name (Legal Business Name): PHILIP J SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 E TANQUE VERDE RD
TUCSON AZ
85715-3477
US

IV. Provider business mailing address

7455 E TANQUE VERDE RD
TUCSON AZ
85715-3477
US

V. Phone/Fax

Practice location:
  • Phone: 520-745-2454
  • Fax: 520-745-0014
Mailing address:
  • Phone: 520-745-2454
  • Fax: 520-745-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD1665
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: