Healthcare Provider Details

I. General information

NPI: 1104839604
Provider Name (Legal Business Name): DEWAYNE RUSH SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8604 112TH ST E
PUYALLUP WA
98373-3857
US

IV. Provider business mailing address

11130 JOLLEYVILLE ROAD SUITE 1500
AUSTIN TX
78759
US

V. Phone/Fax

Practice location:
  • Phone: 253-845-0558
  • Fax: 253-841-0980
Mailing address:
  • Phone: 512-346-8424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6708
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: