Provider Demographics
NPI:1548843980
Name:SMITH, SAMUEL R (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R
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 1:1702 PLACIDA DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5750
Mailing Address - Country:US
Mailing Address - Phone:801-633-0768
Mailing Address - Fax:
Practice Address - Street 1:1601 S SECOND ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5816
Practice Address - Country:US
Practice Address - Phone:505-722-4422
Practice Address - Fax:206-050-5722
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist