MEDICARE: SMITH 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
1	261QD0000X	Dental Clinic/Center	04171	ID
2	261QD0000X	Dental Clinic/Center	DE60311143	WA

General Provider Information

NPI Number	:	1851693337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMITH FAMILY DENTAL

Provider Business Mailing Address
First Line	:	315 W HASTINGS RD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99218-2576
Country	:	US
Telephone Number	:	509-466-2373
Fax Number	:	509-466-4707

Provider Business Practice Location Address
First Line	:	315 W HASTINGS RD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99218-2576
Country	:	US
Telephone Number	:	509-466-2373
Fax Number	:	509-466-4707

Authorized Official
Title or Position	:	DENTIST- OWNER
Name	:	DR. JONATHAN JAY SMITH
Credential	:	DDS
Telephone Number	:	509-466-2373

Provider Enumeration Date	:	12/03/2010
Last Update Date	:	10/08/2012

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