Healthcare Provider Details

I. General information

NPI: 1235153768
Provider Name (Legal Business Name): FREDERIC W. SMITH DMD, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE SUITE 11
PENDLETON OR
97801-3974
US

IV. Provider business mailing address

1100 SOUTHGATE SUITE 11
PENDLETON OR
97801-3974
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-1061
  • Fax: 541-276-0674
Mailing address:
  • Phone: 541-276-1061
  • Fax: 541-276-0674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD 8719
License Number StateOR

VIII. Authorized Official

Name: DR. FREDERIC WARREN SMITH
Title or Position: MANAGING PARTNER
Credential: DMD, MD
Phone: 541-276-1061