Provider Demographics
NPI:1760112080
Name:SMITH, JORDAN (DMD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
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 1:161 12TH AVE W STE C
Mailing Address - Street 2:
Mailing Address - City:GUIN
Mailing Address - State:AL
Mailing Address - Zip Code:35563-2257
Mailing Address - Country:US
Mailing Address - Phone:205-468-3339
Mailing Address - Fax:
Practice Address - Street 1:161 12TH AVE W STE C
Practice Address - Street 2:
Practice Address - City:GUIN
Practice Address - State:AL
Practice Address - Zip Code:35563-2257
Practice Address - Country:US
Practice Address - Phone:205-468-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-11
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0007037-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist