Healthcare Provider Details

I. General information

NPI: 1073516712
Provider Name (Legal Business Name): GORDON PHILLIP SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 W MAPLE RD
WIXOM MI
48393-1820
US

IV. Provider business mailing address

3255 W MAPLE RD
WIXOM MI
48393-1820
US

V. Phone/Fax

Practice location:
  • Phone: 248-669-4141
  • Fax:
Mailing address:
  • Phone: 248-669-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number013824
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: