Provider Demographics
NPI:1538260682
Name:SMITH, DAVID R (DOS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:DOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-1818
Mailing Address - Country:US
Mailing Address - Phone:218-346-7700
Mailing Address - Fax:218-346-5230
Practice Address - Street 1:135 3RD ST NE
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1818
Practice Address - Country:US
Practice Address - Phone:218-346-7700
Practice Address - Fax:218-346-5230
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice