Provider Demographics
NPI:1538232566
Name:MODERN DENTAL PROFESSIONALS-SMITH PA
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS-SMITH PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PC PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-701-6694
Mailing Address - Street 1:8415 DATAPOINT DR STE 1020
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3277
Mailing Address - Country:US
Mailing Address - Phone:479-646-1979
Mailing Address - Fax:
Practice Address - Street 1:3801 CAMDEN ROAD
Practice Address - Street 2:SUITE 11
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603
Practice Address - Country:US
Practice Address - Phone:479-646-1979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR32501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty