1174791990 NPI number — SAMUEL M SMITH DMD PHD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174791990 NPI number — SAMUEL M SMITH DMD PHD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMUEL M SMITH DMD PHD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174791990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1519 EAST MCCORD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-532-1879
Provider Business Mailing Address Fax Number:
618-532-0479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1519 EAST MCCORD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-532-1879
Provider Business Practice Location Address Fax Number:
618-532-0479
Provider Enumeration Date:
02/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
MADISON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
618-532-1879

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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