MEDICARE: JACOB ROGER SMITH 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	122300000X	Dentist	7219	LA

General Provider Information

NPI Number	:	1760056634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB ROGER SMITH DDS

Provider Business Mailing Address
First Line	:	416 N 2ND ST
Second Line	:
City	:	AMITE
State	:	LA
Zip	:	70422-2420
Country	:	US
Telephone Number	:	985-748-4652
Fax Number	:	985-748-7957

Provider Business Practice Location Address
First Line	:	416 N 2ND ST
Second Line	:
City	:	AMITE
State	:	LA
Zip	:	70422-2420
Country	:	US
Telephone Number	:	985-748-4652
Fax Number	:	985-748-7957

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

Provider Enumeration Date	:	05/16/2021
Last Update Date	:	10/13/2022

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Directions to “ JACOB ROGER SMITH DDS” Practice Location

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