MEDICARE: DR. JUSTIN R SMITH D.M.D.

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	D0005975-C1	AL
2	1223G0001X	General Practice Dentistry	DN 19194	FL
3	1223G0001X	General Practice Dentistry	DN19194	FL
4	122300000X	Dentist	DN19194	FL

General Provider Information

NPI Number	:	1497061634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN R SMITH D.M.D.

Provider Business Mailing Address
First Line	:	2407 SAINT ANDREWS BLVD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2170
Country	:	US
Telephone Number	:	850-763-5021
Fax Number	:

Provider Business Practice Location Address
First Line	:	2407 SAINT ANDREWS BLVD STE A
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2170
Country	:	US
Telephone Number	:	850-763-5021
Fax Number	:

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

Provider Enumeration Date	:	08/25/2010
Last Update Date	:	09/29/2022

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