Provider Demographics
NPI:1205929684
Name:SMITH, JOHN ALBERT (DDS PA)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:ALBERT
Other - Last Name:SMITH
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:910 MEDALLION DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2118
Mailing Address - Country:US
Mailing Address - Phone:662-455-9149
Mailing Address - Fax:662-453-1495
Practice Address - Street 1:910 MEDALLION DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2118
Practice Address - Country:US
Practice Address - Phone:662-455-9149
Practice Address - Fax:662-453-1495
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1852791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice