=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003005299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONALD L. SMITHA, DDS, MDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2007
-----------------------------------------------------
Last Update Date | 10/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 812 ALDERMAN RD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32211-6102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-725-8282
-----------------------------------------------------
Fax | 904-725-7197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 812 ALDERMAN RD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32211-6102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-725-8282
-----------------------------------------------------
Fax | 904-725-7197
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DONALD L. SMITHA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 904-725-8282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DN 5802
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------