Healthcare Provider Details

I. General information

NPI: 1275500167
Provider Name (Legal Business Name): A. TODD SMITH, DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 03/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SOUTH HAWTHORNE ROAD
WINSTON SALEM NC
27103-4127
US

IV. Provider business mailing address

1601 SOUTH HAWTHORNE ROAD
WINSTON SALEM NC
27103-4127
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-9550
  • Fax: 336-765-9552
Mailing address:
  • Phone: 336-765-9550
  • Fax: 336-765-9552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number5848
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4949
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number3596
License Number StateNC

VIII. Authorized Official

Name: A TODD SMITH
Title or Position: ORAL SURGEON
Credential: DDS
Phone: 336-765-9550