MEDICARE: DR. THEODORE RHODES SMITH JR. DDS

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	1223G0001X	General Practice Dentistry	0401003897	VA

General Provider Information

NPI Number	:	1699940288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE RHODES SMITH JR. DDS

Provider Business Mailing Address
First Line	:	4221 VIRGINIA BEACH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-1207
Country	:	US
Telephone Number	:	757-486-3919
Fax Number	:	757-486-8792

Provider Business Practice Location Address
First Line	:	4221 VIRGINIA BEACH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-1207
Country	:	US
Telephone Number	:	757-486-3919
Fax Number	:	757-486-8792

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

Provider Enumeration Date	:	04/24/2008
Last Update Date	:	04/24/2008

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