MEDICARE: DR. STACY G SMITH DMD

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	11268	GA

General Provider Information

NPI Number	:	1871698134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY G SMITH DMD

Provider Business Mailing Address
First Line	:	290 HIGHWAY 314
Second Line	:	SUITE A
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-7813
Country	:	US
Telephone Number	:	770-460-6060
Fax Number	:	770-461-0541

Provider Business Practice Location Address
First Line	:	290 HIGHWAY 314
Second Line	:	SUITE A
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-7813
Country	:	US
Telephone Number	:	770-460-6060
Fax Number	:	770-461-0541

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	09/06/2023

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