Healthcare Provider Details

I. General information

NPI: 1265153712
Provider Name (Legal Business Name): JAMES ELLSWORTH SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2878 CAMPUS PKWY STE 1
RIVERSIDE CA
92507-0945
US

IV. Provider business mailing address

27000 W LUGONIA AVE APT 11216
REDLANDS CA
92374-2095
US

V. Phone/Fax

Practice location:
  • Phone: 951-571-0011
  • Fax:
Mailing address:
  • Phone: 949-282-9142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number107829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: