Healthcare Provider Details

I. General information

NPI: 1285764860
Provider Name (Legal Business Name): MICHAEL R SMITH D.M.D.,P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 BUSINESS CENTER DR STE 1
ORANGE PARK FL
32003-7480
US

IV. Provider business mailing address

1520 BUSINESS CENTER DR STE 1
FLEMING ISLAND FL
32003-7480
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-0028
  • Fax: 866-694-8463
Mailing address:
  • Phone: 904-637-0028
  • Fax: 866-694-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: