Provider Demographics
NPI:1144337395
Name:SMITH, JON CHRISTOPHER (DDS)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:CHRISTOPHER
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:PO BOX 6430
Mailing Address - Street 2:1501 SEVENTH AVE
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312
Mailing Address - Country:US
Mailing Address - Phone:304-343-9131
Mailing Address - Fax:304-343-2446
Practice Address - Street 1:1501 SEVENTH AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312
Practice Address - Country:US
Practice Address - Phone:304-343-9131
Practice Address - Fax:304-343-2446
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV34851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4005030000Medicaid