Healthcare Provider Details

I. General information

NPI: 1093735946
Provider Name (Legal Business Name): JAMES ALAN SMITH D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 NW BURNSIDE ROAD
GRESHAM OR
97030-3852
US

IV. Provider business mailing address

8773 NW MARSHALL STREET
PORTLAND OR
97229-5317
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-7480
  • Fax:
Mailing address:
  • Phone: 503-841-5989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5802
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: