=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861882086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S TCHON & DA SMITH DDS MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2015
-----------------------------------------------------
Last Update Date | 01/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 CEDAR RD STE B
-----------------------------------------------------
City | VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92083-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-724-8891
-----------------------------------------------------
Fax | 760-724-7950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 CEDAR RD STE B
-----------------------------------------------------
City | VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92083-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-724-8891
-----------------------------------------------------
Fax | 760-724-7950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | DAVID ALLAN SMITH
-----------------------------------------------------
Credential | DDS, MD
-----------------------------------------------------
Telephone | 760-724-8891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 63419
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------