Healthcare Provider Details

I. General information

NPI: 1700851581
Provider Name (Legal Business Name): JESSE WAYLON SMITH D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WISCONSIN AVE #206
MILWAUKEE WI
53233-2186
US

IV. Provider business mailing address

1100 W WELLS ST #1107
MILWAUKEE WI
53233-2332
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-6508
  • Fax:
Mailing address:
  • Phone: 414-397-0093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5684-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: