Healthcare Provider Details

I. General information

NPI: 1558412379
Provider Name (Legal Business Name): GARY D. SMITH, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 N MAIN ST
ALTUS OK
73521-3102
US

IV. Provider business mailing address

118 N MAIN ST
ALTUS OK
73521-3102
US

V. Phone/Fax

Practice location:
  • Phone: 580-482-4873
  • Fax: 580-482-4895
Mailing address:
  • Phone: 580-482-4873
  • Fax: 580-482-4895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number4265
License Number StateOK

VIII. Authorized Official

Name: DR. GARY D. SMITH
Title or Position: PRES.-OWNER
Credential: D.D.S.
Phone: 580-482-4873