Healthcare Provider Details

I. General information

NPI: 1811038243
Provider Name (Legal Business Name): TIMOTHY BLAIR SMITH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 SE 2ND SUITE 203
PENDLETON OR
97801
US

IV. Provider business mailing address

PO BOX 1246
PENDLETON OR
97801
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-4768
  • Fax: 541-276-9365
Mailing address:
  • Phone: 541-276-4768
  • Fax: 541-276-9365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6928
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: