MEDICARE: RUSSELL SMITH D.M.D

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	5587305-9921	UT

General Provider Information

NPI Number	:	1962666529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL SMITH D.M.D

Provider Business Mailing Address
First Line	:	114 W 550 N
Second Line	:
City	:	CENTERVILLE
State	:	UT
Zip	:	84014-1825
Country	:	US
Telephone Number	:	801-693-8147
Fax Number	:

Provider Business Practice Location Address
First Line	:	6415 BUSINESS PARK LOOP RD STE J
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-6218
Country	:	US
Telephone Number	:	801-693-8147
Fax Number	:

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

Provider Enumeration Date	:	07/14/2008
Last Update Date	:	08/01/2012

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