Healthcare Provider Details

I. General information

NPI: 1750469953
Provider Name (Legal Business Name): MICHAEL A SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6244 POPLAR AVE
MEMPHIS TN
38119-4732
US

IV. Provider business mailing address

6244 POPLAR AVE
MEMPHIS TN
38119-4732
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-4682
  • Fax: 901-507-4523
Mailing address:
  • Phone: 901-682-4682
  • Fax: 901-507-4523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS3279
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: