Healthcare Provider Details

I. General information

NPI: 1134248362
Provider Name (Legal Business Name): JAY SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 PEACHTREE ST NE SUITE # 795
ATLANTA GA
30309
US

IV. Provider business mailing address

999 PEACHTREE ST NE SUITE # 795
ATLANTA GA
30309-3915
US

V. Phone/Fax

Practice location:
  • Phone: 404-872-3140
  • Fax:
Mailing address:
  • Phone: 404-872-3140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number10743
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: