Healthcare Provider Details

I. General information

NPI: 1164879052
Provider Name (Legal Business Name): SMITH ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 BUSINESS CENTER DR SUITE 2
ORANGE PARK FL
32003-9011
US

IV. Provider business mailing address

1520 BUSINESS CENTER DR SUITE 2
ORANGE PARK FL
32003-9011
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-0028
  • Fax: 904-644-8230
Mailing address:
  • Phone: 904-637-0028
  • Fax: 904-644-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN13788
License Number StateFL

VIII. Authorized Official

Name: DR. MICHAEL R. SMITH
Title or Position: OWNER
Credential: DMD
Phone: 904-637-0028