Healthcare Provider Details

I. General information

NPI: 1174582928
Provider Name (Legal Business Name): PAUL R SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5345 SPRING STREET
DAVENPORT IA
52807-0000
US

IV. Provider business mailing address

5345 SPRING ST
DAVENPORT IA
52807-2764
US

V. Phone/Fax

Practice location:
  • Phone: 563-359-1601
  • Fax: 563-355-7111
Mailing address:
  • Phone: 563-359-1601
  • Fax: 563-355-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7850
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8846
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: