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General NPI Number Information
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NPI Number | 1497061634
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Entity Type | Individual
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Provider Name | JUSTIN R SMITH D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/25/2010
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Last Update Date | 09/29/2022
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Provider Practice Location Address
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Address Line | 2407 SAINT ANDREWS BLVD STE A
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City | PANAMA CITY
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State | FL
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Zip | 32405-2170
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Country | US
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Telephone | 850-763-5021
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Fax |
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Provider Business Mailing Address
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Address Line | 2407 SAINT ANDREWS BLVD
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City | PANAMA CITY
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State | FL
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Zip | 32405-2170
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Country | US
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Telephone | 850-763-5021
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D0005975-C1
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN 19194
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN19194
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN19194
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License Number State | FL
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