Provider Demographics
NPI:1902077530
Name:SMITH, MARK PHILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PHILIP
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4205
Mailing Address - Country:US
Mailing Address - Phone:434-792-2845
Mailing Address - Fax:434-792-1494
Practice Address - Street 1:816 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4205
Practice Address - Country:US
Practice Address - Phone:434-792-2845
Practice Address - Fax:434-792-1494
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010049381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice