Healthcare Provider Details

I. General information

NPI: 1376508952
Provider Name (Legal Business Name): GREGORY JAMES SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 NORTH DALE STREET
ST. PAUL MN
55117
US

IV. Provider business mailing address

1651 NORTH DALE STREET
ST. PAUL MN
55117
US

V. Phone/Fax

Practice location:
  • Phone: 651-488-5888
  • Fax: 651-488-8425
Mailing address:
  • Phone: 651-488-5888
  • Fax: 651-488-8425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9117
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9117
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: