Provider Demographics
NPI:1134454127
Name:SMITH, DOUGLAS HOWARD (DDS)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:HOWARD
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 1:16400 SOUTH MARKS ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA STATION
Mailing Address - State:OH
Mailing Address - Zip Code:44028
Mailing Address - Country:US
Mailing Address - Phone:440-846-1304
Mailing Address - Fax:
Practice Address - Street 1:130 S 130 ST
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691
Practice Address - Country:US
Practice Address - Phone:330-264-9678
Practice Address - Fax:330-466-3077
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-16682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0466759Medicaid