MEDICARE: DR. MICHAEL SHANE SMITH D.D.S.

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	DN013493	GA
2	122300000X	Dentist	DS 7804	TN

General Provider Information

NPI Number	:	1992916175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL SHANE SMITH D.D.S.

Provider Business Mailing Address
First Line	:	512 SCOTTER HILLS LN
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-5541
Country	:	US
Telephone Number	:	804-828-6498
Fax Number	:

Provider Business Practice Location Address
First Line	:	1202 CLEO WAY STE 3
Second Line	:
City	:	DALTON
State	:	GA
Zip	:	30720-8356
Country	:	US
Telephone Number	:	804-828-6498
Fax Number	:

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

Provider Enumeration Date	:	05/27/2007
Last Update Date	:	07/08/2007

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