Healthcare Provider Details

I. General information

NPI: 1619168556
Provider Name (Legal Business Name): JOSHUA TAYLOR SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30-023817
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number23462
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: