Healthcare Provider Details

I. General information

NPI: 1134478647
Provider Name (Legal Business Name): ROBERT E. SMITH DDS MPH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 NEW HAVEN AVE
DERBY CT
06418-2154
US

IV. Provider business mailing address

115 NEW HAVEN AVE
DERBY CT
06418-2154
US

V. Phone/Fax

Practice location:
  • Phone: 203-732-4747
  • Fax: 203-734-4101
Mailing address:
  • Phone: 203-732-4747
  • Fax: 203-734-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number010810
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number007110
License Number StateCT

VIII. Authorized Official

Name: LYNANNE MADGIC
Title or Position: OFFICE MANAGER
Credential:
Phone: 203-732-4747