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NPI Code Detail

MEDICARE: PAUL D SMITH D.D.S., S.C. DBA JACKSON PARK FAMILY DENTAL

MEDICARE: PAUL D SMITH D.D.S., S.C. DBA JACKSON PARK FAMILY DENTAL
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
1261QD0000XDental Clinic/Center
2122300000XDentist

General Provider Information

NPI Number : 1558023622
Entity Type Code : Organization
Provider Name (Legal Business Name) : PAUL D SMITH D.D.S., S.C. DBA JACKSON PARK FAMILY DENTAL
Provider Business Mailing Address
First Line : 3520 W OKLAHOMA AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53215-4175
Country : US
Telephone Number : 414-645-0365
Fax Number :
Provider Business Practice Location Address
First Line : 3520 W OKLAHOMA AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53215-4175
Country : US
Telephone Number : 414-645-0365
Fax Number :
Authorized Official
Title or Position : PRACTICE PARTNER
Name : DR. DANIEL SMITH
Credential :
Telephone Number : 414-645-0365
Provider Enumeration Date : 10/06/2021
Last Update Date : 04/18/2023

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