Healthcare Provider Details

I. General information

NPI: 1831279538
Provider Name (Legal Business Name): JUSTIN CRAIG SMITH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/20/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 3RD AVE NORTH
PAYETTE ID
83661
US

IV. Provider business mailing address

1105 3RD AVE NORTH
PAYETTE ID
83661
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-9763
  • Fax: 208-642-3554
Mailing address:
  • Phone: 208-642-9763
  • Fax: 208-642-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3526
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: