Healthcare Provider Details

I. General information

NPI: 1427055441
Provider Name (Legal Business Name): JERRY WAYNE SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 S YALE AVE
TULSA OK
74136-8305
US

IV. Provider business mailing address

6565 S YALE AVE
TULSA OK
74136-8305
US

V. Phone/Fax

Practice location:
  • Phone: 918-492-1106
  • Fax: 918-492-1834
Mailing address:
  • Phone: 918-492-1106
  • Fax: 918-492-1834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number23196
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: