Healthcare Provider Details

I. General information

NPI: 1891844312
Provider Name (Legal Business Name): JEREMY JAMES SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 MEDICAL PARKWAY SUITE 203
AUSTIN TX
78756
US

IV. Provider business mailing address

4310 MEDICAL PARKWAY SUITE 203
AUSTIN TX
78756
US

V. Phone/Fax

Practice location:
  • Phone: 512-459-3129
  • Fax: 512-459-3431
Mailing address:
  • Phone: 512-459-3129
  • Fax: 512-459-3431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number14126
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: