Provider Demographics
NPI:1871473058
Name:SMITH, BENJAMIN DALE
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HIDDEN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:GA
Mailing Address - Zip Code:31064-4198
Mailing Address - Country:US
Mailing Address - Phone:678-502-8754
Mailing Address - Fax:
Practice Address - Street 1:230 S CLARK RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2750
Practice Address - Country:US
Practice Address - Phone:972-291-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-06
Last Update Date:2025-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist