Healthcare Provider Details

I. General information

NPI: 1073770152
Provider Name (Legal Business Name): FREDERIC W SMITH MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2008
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 PETERMAN DR
ALEXANDRIA LA
71301-3433
US

IV. Provider business mailing address

1403 PETERMAN DR
ALEXANDRIA LA
71301-3433
US

V. Phone/Fax

Practice location:
  • Phone: 318-443-7208
  • Fax: 318-443-0046
Mailing address:
  • Phone: 318-443-7208
  • Fax: 318-443-0046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number23648
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6461
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: