Healthcare Provider Details

I. General information

NPI: 1801906615
Provider Name (Legal Business Name): DANE E SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 5TH ST
BROOKINGS OR
97415-9702
US

IV. Provider business mailing address

3500 CEDAR ST
NORTH BEND OR
97459-1108
US

V. Phone/Fax

Practice location:
  • Phone: 541-469-5373
  • Fax: 541-412-0177
Mailing address:
  • Phone: 541-756-3683
  • Fax: 541-756-1974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD4773
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: