Healthcare Provider Details

I. General information

NPI: 1649371196
Provider Name (Legal Business Name): CHRISTOPHER RUSSELL SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 GRANDVIEW AVE
COLUMBUS OH
43212-3437
US

IV. Provider business mailing address

2601 CHARING RD
COLUMBUS OH
43221-3600
US

V. Phone/Fax

Practice location:
  • Phone: 614-486-7378
  • Fax:
Mailing address:
  • Phone: 614-354-2367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30022002
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: