MEDICARE: DR. IVAN J 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	0014805	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942373584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVAN J SMITH DMD

Provider Business Mailing Address
First Line	:	1190 EDGEWOOD AVE W
Second Line	:	SUITE B
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3419
Country	:	US
Telephone Number	:	904-764-4549
Fax Number	:	904-764-2263

Provider Business Practice Location Address
First Line	:	1190 EDGEWOOD AVE W
Second Line	:	SUITE B
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3419
Country	:	US
Telephone Number	:	904-764-4549
Fax Number	:	904-764-2263

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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