Provider Demographics
NPI:1902236268
Name:SMITH, BRIAN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
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 1:715 W MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-1564
Mailing Address - Country:US
Mailing Address - Phone:712-213-0179
Mailing Address - Fax:712-213-0186
Practice Address - Street 1:715 W MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1564
Practice Address - Country:US
Practice Address - Phone:712-213-0179
Practice Address - Fax:712-213-0186
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-090511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice