Provider Demographics
NPI:1730241340
Name:SMITH, PETER R (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
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 4473
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29903-4473
Mailing Address - Country:US
Mailing Address - Phone:843-525-0616
Mailing Address - Fax:
Practice Address - Street 1:700 PARRIS ISLAND GATEWAY
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29903-4473
Practice Address - Country:US
Practice Address - Phone:843-525-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 29571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice