MEDICARE: DR. JACK OWEN SMALLEY D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DD1918	NM
2	1223G0001X	General Practice Dentistry	DD1918	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487611331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK OWEN SMALLEY D.D.S.

Provider Business Mailing Address
First Line	:	2650 E PINON FRONTAGE RD BLDG 300
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87402-5084
Country	:	US
Telephone Number	:	505-327-3331
Fax Number	:	505-327-0873

Provider Business Practice Location Address
First Line	:	2650 E PINON FRONTAGE RD BLDG 300
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87402-5084
Country	:	US
Telephone Number	:	505-327-3331
Fax Number	:	505-327-0873

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	11/01/2018

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