MEDICARE: DR. JESSE WAYLON SMITH 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	1223P0700X	Prosthodontics	5684-015	WI

General Provider Information

NPI Number	:	1700851581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSE WAYLON SMITH D.D.S

Provider Business Mailing Address
First Line	:	1100 W WELLS ST
Second Line	:	#1107
City	:	MILWAUKEE
State	:	WI
Zip	:	53233-2332
Country	:	US
Telephone Number	:	414-397-0093
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 W WISCONSIN AVE
Second Line	:	#206
City	:	MILWAUKEE
State	:	WI
Zip	:	53233-2186
Country	:	US
Telephone Number	:	414-288-6508
Fax Number	:

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	07/08/2007

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